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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culberison City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVESTIGATIONS <br /> I . GENERAL INSTRUCTIONS: <br /> L-2. <br /> L�1. Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, piping .streets and <br /> adjacent properties (north toward the top of the page), location or nearby septic <br /> tanks, leachfields, buildings, and underground public utility lines (including water, <br /> sanitary sewer and storm sewer) . <br /> � ON FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" form and remit <br /> $35.00 permit fee. <br /> P-14. The ON FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" shall be signed by the <br /> licensed contractor, or the licensed contractor (Class 57) shall in writing authorize <br /> �,� an agent's signature. <br /> L`T 5. The licensed contractor applying for the permit shall provide to the San Joaquin <br /> L�tt1 Health District a comi�leted "CONTRACTOR QUESTIONNAIRE" and proof of Worker's <br /> u' �pfmpensation insurance, or have said documents on file with the SJLHD. <br /> Ft <br /> WVO 6. Off-site well construction in public easements will require that a copy of the <br /> municipality's encroachment permit be submitted to the SJLHD prior to the issuance of <br /> the monitoring well permit. <br /> OCC 7. Off-site well construction on parcels of different ownership will require a letter of <br /> authorization from the property owner granting permission to drill. <br /> A separate and complete "APPL,ICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT" <br /> form and $35.00 permit fee is required for each DIFFERING street address. <br /> 2 <br /> 9. Complete the "Authorization to Release Analytical Data" form. <br /> L`Y 10. Complete the "APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES" arid submit the <br /> -, appropriate consultation review fee. <br /> 'I 11. Assessment work plans and/or reports should follow the guideline "SUBSURFACE <br /> INVESTIGATIVE FORMATS". <br /> �KO 12. Lead agency involvement (i.e., DHS/TSCD or RWQCB or EPA) with the prorsed <br /> investigative site activity will require that written comments, from the designated <br /> lead agency, be submitted to the San Joaquin Local Health District prior to the <br /> issuance of any local subsurface investigative permits. <br /> 13. The current workload volume is being managed by a 60-day backlog of chronologically <br /> received environmental assessment/remediation reports and/or work plans. The San <br /> Joaquin Local Health District has established a priority review process which is an <br /> option available upon written request. The priority review is conducted during off <br /> hours at an overtime rate of $52.`;0 an hour. Scheduling of the priority review is <br /> accomplished by individual staff members, but can generally occur within 10 working <br /> days of the receipt of written request and the submitted assessment document. <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />