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PUBLI11EALTH SER tES SAN JOAQUIN COUNTY :z JOGI KHANNA M.D.,M.P.H. Health Officer P.O. Box 2009 (1601 East Hazelton Avenue] • Stockton,California 95201 (209) 468-34GQ1,* APPLICATION FOR PERMIT TO CONSTRUCT MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE- INVESTIGATION I. GENERAL PERMITTING INSTRUCTIONS FOR LOP SITE ONLY: L1. Complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, / ENVIRONMENTAL HEALTH DIVISION' form in triplicate and remit sag.00 permit fee. ,J 2. 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 sewer and storm sewer). All underground public utility lines, site utility lines, and product lines should be identified and located prior to drilling. V 3. The 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DMSION' shall be signed by the licensed contractor, or the licensed contractor j (Class 57) shall in writing authorize an agent's signature. L, 4. The licensed contractor applying for the permit shall provide to the San Joaquin Public Health Services, Environmental Health Division a completed 'CONTRACTOR QUESTIONNAIRE" and proof of Worker's Compensation insurance, or have said documents on file with the SJC/PHS/EHD. Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be submitted to the SJC4`PIIS/EI-1D, prior to the issuance of the monitoring well permit. Off-site well construction on parcels of different ownership will require a letter of authorization from the property owner granting permission to drill. Lam, 7. A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drilling permits. (See attached example) A separate and complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DMSION' form and sag-oo permit fee is required for each DIFFERING street address. u� 9. Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. ON. A SPECIAL PERMIT request to allow construction of monitoring wells which are located less 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 provision set forth in the San Joaquin County Ordinance Code Section 5-4105 and page 2, paragraph I, D at the associated Rules and Regulations. EH 23 045B REVISED 10/S9 A Division of San Joaquin County Health Care Services 40