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08-08-90 03: 18PM FROM TV ENG • PO4 PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY a: :a ]OGI KHANNA M.D„IAX.H. Health Officer 4�k, P.O. Box 2009 " (1601 East Hazelton Avenue) " Stockton,California 95201 (209) 468.3400 `YI APPLICATION FOR PERMIT TO CONSTRUCT MONITORING WELLS AND/OR SOILBORINGS FOR THE PURPOSE OF SUBSURFACE INVESTL GENERAL pERMITTrNG INSTRUCTIONS FOR NON PILOT ONLY: J Complete "APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTALHEALTH DIVISION" form in triplicate, and remit $3s'tlO��mit fee, Y7 � Include a detailed site map showing tank location and type, piping, streets and adjacent properties (north toward the top of the page), location of nearby septic tanks, leachfields, buildings, and underground public utility lines including water, sanitary serer and storm sewer). All underground public utility lines, site utility lines, and product ) ^/ lines should be identified and located prior to drilling. Z I/ 3. The "APPLICATION FOR PBRMCI'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEAL'T'H DIVISION" shall be signed by the licensed contractor, or the licensed contractor (Class 57) shall in writing authorize an agent's signature. The licensed contractor applying for the permit shall provide to the San Joaquin County a completed "CONTRACTOR QUESTIONNAIRE" and proof of Worker's Compensation insurance, or have said documents an file with the SJCJPHS/EHD. W 5. Off-site well construction in public casements will require that a copy of the municipality's encroachment permit be submitted to SJC/PHS/EHD prior to the issuance of the monitoring well permii. Lj 6. Off.site well construction on parcels of different ownership will require a letter of authorization from the property owner granting permission to drill. JOAQUIN u 7 SERVICCESand ENVIRcomplete tNMENTAL HEALTH DIVISION" form and $355.00 perrmmUNTYsPUBLredHEALTHreach DIFFERING street address, Complete the "Authorization to Release Analytical Data" form. ® 9. Complete the "APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES" and submit the appropriate consultation review fee. 2 • 10. Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. u 11. SPECIAL PERMIT request to allow Construction of monitoring wells which arc lucated loss than the, required .isolation distances from potential sources of bacterial and/or chemical contamination as specified in the Rules and Regulations for San Joaquin County Ordinance #1862, will be reviewed and monitored in accordance with the provisions set fedi In the San Joaquin County Ordinance Code Section 5.4105 and page 2, paragraph I, D, of the associated Rules and Regulations. L' 12, Load agency involvement (i.e., DHS/I'SCD or RWQCB or EPA) with the proposed investigative site activity will require that written comments, from the designated lead agency, be submitted to the San Joaquin County Public Health Services, Environmental Health Division prior to the issuance of any local subsurface investigative permits.