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PUBLI! HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />JOG! KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue). • Stockton, California 95201 cigoP <br />(209) 468-34(44'2,o <br />APPLICATION FOR PERMIT TO CONS I Rucr <br />MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br />INVESTIGATION <br />I. GENERAL PERMITTING INSTRUCTIONS FOR LOP SITE ONLY: <br />Complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br />ENVIRONMENTAL HEALTH DIVISION' form in triplicate and remit $89.00 permit fee. <br />Include a detailed site map showing tank location and type, piping, streets and adjacent properties (north toward <br />the top of the page), location of nearby septic tanks, leachilelds, buildings, and underground public utility lines <br />(including watcr, 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 />The 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, <br />ENVIRONMENTAL HEALTH DIVISION' shall be signed by the licensed contractor, or the licensed contractor <br />(Class 57) shall in writing authorize an agent's signature. <br /> <br />4. 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 />Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be <br />submitted to the SJC/PI-IS/EHD, prior to the issuance of the monitoring well permit. <br /> <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 />L..; 7. <br />8. <br />A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drilling permits. <br />(See attached example) <br />A separate and complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES, ENVIRONMENTAL HEALTH DIVISION' form and sa9.0o permit fee is required for each <br />DIFFERING street address. <br />Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. <br />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 />r-1 <br />EH 23 045B <br />REVISED 10/89 <br />A Division of San Joaquin County Health Care Services <br />Z 1.