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�4 0 ' c•G b`�, 3 SAN JOAQUIN COUNTY < ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue,3d Floor, Stockton, CA 95202-2708 ql . Telephone.(209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd APPLICATION REQUIREMENTS FOR A PERMIT TO DRILL SAN JOAQUIN COUNTY ORDINANCE CODE REQUIRES THAT A WELL PERMIT BE ISSUED BY THE ENVIRONMENTAL HEALTH DEPARTMENT(EHD) PRIOR TO DRILLING/BORING. If the purpose of the drilling/boring is to identify the presence, absence or extent of soil or groundwater contamination, the following documents must be completed, signed and submitted with the appropriate fees to the Site Mitigation Unit(Unit IV) of the EHD. Other unit staff in the EHD approves well/boring permits for other purposes. Sites in the Local Oversight Program (LOP) do not need to submit items 2, 3, and 5. ITEMS TO BE SUBMITTED: 1. Work Plan, The work plan should describe the site history and the purpose and scope of the proposed investigation. This should include drilling and sampling procedures, laboratory analyses,well and/or boring construction/destruction methods, disposal of soil and/or water generated, a site map and a safety plan. The work plan will be reviewed by EHD staff to determine whether permit(s)may be issued. If a written response is expected from the EHD at the end of the investigation,this request must be included with the work plan so appropriate advice can be provided by the EHD. 2. Master File Record Information Form. This form must be completed to identify the site owner name and address, the facility name and address, and the party responsible for paying any additional charges associated with the proposed activity. The form must be signed by the individual accepting responsibility for any additional charges. 3. Site Mitigation Fees.A fee of$279(3 hour minimum charge) must be submitted with the work plan. Checks should be made payable to"EHD." All EHD staff time is charged at the rate of $93/hour. If more than 3 hours of time is required,the party identified on the Master File Record form as responsible for additional charges will be billed for the additional time. 4. Well Permit Application. A Well Permit Application form must be completed and remitted with the$89 permit fee. The Application shall be signed by a C-57 licensed contractor,or the C-57 licensed contractor shall authorize an agent's signature in writing. The Licensed Contractor Declaration must be completed and will be used to expedite license and workers compensation verification. a. Prior to issuance of permits for off-site drilling in public easements, a copy of the encroachment permit issued by the public entity must be submitted to the EHD. b. Off-site drilling on parcels not owned by the owner identified on the Master File Record form require a letter of authorization from the property owner granting permission to drill. c. On-site drilling by third parties (not the property owner or operator) requires a letter of authorization from the property owner granting permission to drill. d. A separate and complete Application for Permit and$89 fee is required for each differing parcel and/or street address. 5. Work Plan Approval Letter. If the Central Valley Regional Water Quality Control Board, Department of Toxic Substances Control or other agency has regulatory authority for oversight, a copy of their written approval of the proposed work must be provided. PLEASE NOTE: If contamination is identified as a result of this investigation the appropriate agency will be sent a copy of the hazardous waste discharge notification and the site will be so listed on the EHD database. 29-02-003 Requirements for IV 3/23/2005