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PUBLIC 'IEALTH SERVICES <br /> p^`tUl~ Po <br /> SAN JOAQUIN COUNTY <br /> X <br /> JOGI KHANNA M.D.,M.P.H. <br /> •: t < <br /> Health Officer <br />! �P.O. Dox 2009 . (1601 East Hazelton Avenue) Stockton,California 95201 <br /> ��liF�pes'P <br /> (209) 468-3400 <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVESTIGATION <br /> i <br /> GENERAL PERMPIT'ING INSTRUCITONS FOR PILOT SITE ONLY- <br /> h L✓Cnmplctc 'APPLiCATTON FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION' form in triplicate and remit SUM permit fee. <br /> 2 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, leachficlds, buildings, and underground public utility lines <br /> (including water, 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 /> 3. .-'� Thc 'APPLICATTON FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION" shall be signal by the licensed contractor, or the licensed contractor <br /> (Class 57) shall in writing authorize an agent's signature. <br /> 4.,,,-'Thc licensed contractor applying for the permit shall provide to the San Joaquin Public Health Services, <br /> 1 Environmental Health Division a completed 'CONTRACTOR QUESTIONNAIRE' and proof of Worker's j <br /> II Compensation insurance, or have said documents on file with the SJC/PHS/EHD. <br /> 15. Off-site well construction in public casements will require that a copy of the municipality's encroachment permit be <br /> submitted to the SJCRHS/EHD, prior to the issuance of the monitoring well permit. <br /> i <br /> 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 /> j 7. ✓ A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drilling permits. <br /> (See attached example) <br /> 8.t,,- A separate and complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES, ENVIRONMENTAL HEALTH DIVISION' form and-,$11t W permit fee is required for each <br /> DIFFERING street address. syOd <br /> 1p 9. (/ Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. <br /> 1 10.�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 I, D at the <br /> associated Rules and Regulations. <br /> [ 23 045B <br /> !VISED 10/89 <br /> A Division of San Joaquin County Health Care Services <br />