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' PUBLIC 1 LVALTH SERVI(tS <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 4G/FORe <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> ENVIRONMENTAL ASSESSMENTS <br /> All assessment activities at a given site are to be documented in reports <br /> submitted to San Joaquin County Public Health Services, Environmental Health <br /> Division (PHS-EHD) and/or to any other governmental agency performing <br /> regulatory oversight. In order to expedite the issuance of permits and field <br /> activities the following are to be submitted. <br /> ITEMS TO BE SUBMITTED <br /> 1. Work plan. It should describe the site's history and the proposed investigation. <br /> This should include drilling and sampling procedures, laboratory analyses, well <br /> construction or boring destruction method, disposal of soil and/or water <br /> generated, a site map and a safety plan. The work plan will be reviewed by <br /> PHS-EHD staff to determine whether the necessary permit(s) may be issued for <br /> the proposed work. PHS-EHD will not provide written comments in this review <br /> process. <br /> -0\6 2. Master File Record Information form. The site owner name and address, <br /> r e e�7 the facility name and address, and the party responsible for paying any additional <br /> fees must be completed. The form must be signed by the individual authorizing <br /> ed the billing. <br /> 5ab fln1� <br /> ka�e orlll 3. Site Mitigation Fees. A fee of$261 (minimum 3 hours of time) must be <br /> s k submitted. Staff time is charged at $87/hour. If more than 3 hours of staff time is <br /> required, the party identified on the Master File Record will be billed for the <br /> additional time. <br /> 4. Well Permit Application. Complete the Application for Permit form in triplicate <br /> and remit an $89 permit fee. The Application shall be signed by the licensed <br /> contractor, or the licensed contractor (Class 57) shall in writing authorize an <br /> agents signature. <br /> a. Off-site well construction in public easements will require that a copy of the <br /> municipality's encroachment permit be submitted to PHS-EHD prior to the <br /> issuance of the Permit. <br /> b. Off-site well construction on parcels of different ownership will require a letter <br /> of authorization from the property owner granting permission to drill. <br /> c. A separate and complete Application for Permit and $89 fee is required for <br /> each differing parcel and/or street address. <br /> A Division of San Joaquin County Health Care Services <br />