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9b 4RD OF TRUSTEES SAN JOAOLIIN LOCAL HEALTH DISTRICT <br /> At Crow, Prea. SERVING <br /> Tommy Eony Joyce,Secy o ee Prea. 1601 East Hazelton Avenueecy. Fan Joaquin county <br /> James F.Culbertson Stockton, California 95205 City of Manteca <br /> Jahn D.Mast,M.D. City of Eacalon <br /> JOGI KNANNA, M.D„ M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia SchuMathews City of Tracy <br /> Thomas 9chubarl D.V.M. <br /> Daphne Shaw City of Ripon <br /> Harvey Williams,Ph.D. San Joaquin County <br /> City of Stockton <br /> APPLICATION FOR PERMIT TO CONSTRUCT Sen Joaquin Counry <br /> MONITORING, WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVESTIGATIONS <br /> I . GENERAL INSTRUCTIONS: <br /> ❑ <br /> I. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and ty{�e, <br /> adjacent proppeerties (north toward the to of the gpaagg piping streets and <br /> tanks, leachfields, buildings, and underground puhlic)utilittion o, nearby septic <br /> sanitary sewer and storm sewer) . Ynes ( including water, <br /> 3. Complete "APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" form and remit <br /> $35.00 permit fee. <br /> The <br /> ❑ <br /> I . licensedLcontractorR or the lAcen�edUcontracrorE(C1assI57Rlghals nl,betgngnautby horize <br /> an agent's signature. <br /> ❑ 5. The licensed contractor appppllyy1ing for the ppeermit shall rovide to ppthe San Joaquin <br /> Compensation Dnsurance, ormhaveesaidd doccuumentsOonSfile with, thedSJLHDf of Worker 's <br /> ❑ 6. Off-site well construction in public easements will require co yyof the <br /> municipality's encroachment permit be submitted to the uire prior that a COPthe issuance of <br /> the monitoring well permit. <br /> ❑ 7. Off-site well construction on parcels of different ownership will <br /> authorization from the property owner granting permission to drill .require a letter (-,f <br /> ❑ 8 form pandt$35no0cpermitefee is requOredFOR forI eacT DIFFERAQQUING NLPOCALaHEALTH DISTRICT" <br /> ❑ s. <br /> 9- Complete the "Authorization to Release Analytical Datan form, <br /> ❑ 10. Complete the "APPLICATION ENVIRCNMFNTAL HEALTH PERMIT/SERVICES" and submit the <br /> appropriate consultation review fee. <br /> ❑ 11. Assessment workplans and/or reports should follow the guideline "SUBSURFACE <br /> INVESTIGATIVE FORMATS", <br /> L 12. Lead a ency involvement it w1 DNS/TSCD Or RWQCn or ZPA) with the proposed <br /> lead�agencly,ebelsubmittedtcowthe Sann oaquintLocaltHealthmDistrict prior designated <br /> Issuance of any local subsurface investigative permits, <br /> ❑ 13. The <br /> nttaloa sesume smentt/:emediationbreporradaand or lv9rkfplanonolTgeCSaiy <br /> Joaquin Local Health District has established a priorit review <br /> option available upon written request. The priority review is which an <br /> hours at he overtime rate of $ff-50 an hour. . Scheduling of the priority review is <br /> of <br /> daysmooflthedreceiptiOfdWrittenfrequesstrandothecsubmittedle soccur eszmentldocumentWorkirg <br /> EH 23 071 (REV 1/89) <br /> Administration Clinical Services Environmental Health <br /> 488.3400 468-3830 Pu011C Health Nursing <br /> 468-3420 468-7860 <br /> Air Polfutlon Community Services <br /> 488-3410 488-3820 Laboratory IC <br /> W <br /> 488.3480 4aa is <br /> '��'N[_bIHf3 <br /> Id"c,fII13,1c1HW N0-:I1,�,3Hj� LStOT 6E. 'HT '333 <br /> AIDS li„air„».,,.. ..._.e... <br />