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PUBIC HEALTH SEIVICES oU.N <br /> SAN JOAQUIN COUNTY '9'P <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton, California 95201 cqc/Fops <br /> (209) 468-3400 <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVES'T'IGATION <br /> L GENERAL PERMITTING INSTRUCTIONS FOR PILOT SITE ONLY: <br /> LL 1. Complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION• form in triplicate and remit—p0 permit fee. <br /> W 2. Include a detailed site map showing tank location and e, piping, streets and adjacent properties (north toward <br /> the top of the page), location of nearby septic tanks, lea h0 , buildings, and underground public utility lines <br /> (including water, sanitary sewer and storm sewer). All underground public utility lines, site utility lines, and <br /> product lines should be identified and located prior to drilling. <br /> u 3. The 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION' shall be signed by the licensedcontractor, or the Ii ns contractor <br /> (Class 57) shall in writing authorize an agent's signature. <br /> 24. The licensed contractor applying for the permit shall provide to the San Joaquin Public Health Services, <br /> Environmental Health Division a completed 'CONTRACTOR QUESTIONNAIRE' and proof of Worker's <br /> Compensation insurance, or have said documents on file with the SJC/PHS/EHD. <br /> n <br /> u 5. Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be <br /> submitted to the SJC/PHS/EHD, prior to the issuance of the monitoring well permit. <br /> r, <br /> L-, 6. Off-site well construction on parcels of different ownership will require a letter of authorization from the property <br /> owner granting permission to drill. <br /> �C 7. A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drilling permits. <br /> (See attached example) <br /> L-1 8. A separate and complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES, ENVIRONMENTAL HEALTH DMSION' form and0 permit fee is required for each <br /> DIFFERING street address. q z� <br /> LJ 9. Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. <br /> 10. A SPECIAL PERMIT request to allow construction of monitoring wells which are located less than the required <br /> isolation distances from potential sources of bacterial and/or chemical contamination as specified in the Rules and <br /> Regulations for San Joaquin County Ordinance #1862, will be reviewed and monitored in accordance with the <br /> provision set forth in the San Joaquin County Ordinance Code Section 5-4105 and page 2, paragraph 1, D at the <br /> associated Rules and Regulations. <br /> EH 23 045B Aw <br /> REVISED 10/89 t ,fa <br /> h <br /> Cp�tib,l Ty <br /> SES <br /> A Division of San Joaquin County Health Care Services <br />