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PUBLIC HEALTH SERVICES <br /> oP. •�..c <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. X <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) " Stockton,California 95201 <br /> (209) 468-3400 <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING VMI S AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVESTIGATION <br /> L GENERAL PERMITTING INSTRUCTIONS FOR EqpI SITE ONLY <br /> u 1. Complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> .Lr V. 2". <br /> v,� ENVIRONMENTAL HEALTH DIVISION" form in triplicate and remit $35.00 it 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, leachfields, 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 /> � <br /> . The -APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DMSION" shall be signed by the licensed contractor, or the licensed contractor <br /> (Class 57) shall in writing authorize an agent's signature. <br /> 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 /> u 5. Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be <br /> submitted to the SJC/PHS/EM, prior to the issuance of the monitoring well permit. <br /> u 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 /> u 7. A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drillingpermits. <br /> (See attached example) <br /> M <br /> 8. A separate and complete "APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES, ENVIRONMENTAL HEALTH D SION" form and.$35.00 permit fee is required for each <br /> DIFFERING street address. <br /> u 9. Assessment work plans and/or reports should fo e low t appropriate regulatory agency's guidelines. <br /> U.�rT WA vrz the appropriate <br /> �c�vrivw6v�w�tn��„ <br /> 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 /> EH 23 045B <br /> REVISED 10/89 <br /> A Division of San Joaquin County Health Care Services <br />