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•BOARD of TRUSTEES `,AN JOAQUIN LOCAL HEALTH ClwTRICT SERVING At Crow,Pres. San Joaquin County Earl Pimentet,Vice Pres. 1601 East Hazelton Avenue City of Manteca Tommy Joyce,Secy. Stockton, California 95205 City of Escalon James F.Culbertson City of Lodi John D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy Virginia Mathews City of Ripon Thomas Schubert,D.V.M. San Joaquin County Daphne Shaw City of Stockton Harvey Williams,Ph.D. San Joaquin County APPLICATION FOR PERMIT TO CONSTRUCT MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE INVESTIGATIONS I. GENERAL INSTRUCTIONS: 1�[ 1 Submit: all information in triplicate. USE CARBONS. 2. Include a detailed site map showing tank location and type, piping streets and adjacent properties (north toward the top of the page), location o nearby septic tanks, )eachfields, buildings, and underground public utility lines (including water, sanitary sewer and storm sewer) . Complete "APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" form and remit $35.00 permit fee. The "APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" 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 Loral Health District a completed "CONTRACTOR QUESTIONNAIRE" and proof of Worker's Compensation insurance, or have said documents on file with the SJLHD. C] 6. Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be submitted to the SJLHD prior to the issuance of the monitoring well permit. 7. Off-site well construction on parcels of different ownership will require a letter of authorization from the property owner granting permission to drill. 0 8. A separate and complete "APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" form and $35.00 permit fee is required for each DIFFERING street address. 9 Complete the "Authorization to Release Analytical Data" form. 0 10. Complete the "APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES" and submit the appropriate consultation review fee. El 11. Assessment work plans and/or reports should follow the guideline "SUBSURFACE INVESTIGATIVE FORMATS". 12. Lead agency involvement (i.e., DHS/TSCD 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 Local Health District prior to the issuance of any local subsurface investigative permits. 13 The current workload volume is being managed by a 60-day backlog of chronologically received environmental assessment/remediation reports and/or work plans. The San Joaquin Local Health District has established a priority reviewprocess which is an option available upon written request. The priority review is conducted during off hours at an overtime rate of $52.50 an hour. Scheduling of the priority review is accomplished by individual staff members, but can generally occur within 10 working days of the receipt of written request and the submitted assessment document. EH 23 071 (REV 1/89) Administration Clinical Services Environmental Health Public Health Nursing 468-3400 468-3830 468-3420 468-3860 Air Pollution Community Services Laboratory WIC 468-3470 468-3820 468-3460 468-3280 AIDS Information 468-3820