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f t;J()~ m.;.JJ 2009 ANNUAL GEOTECHNICAL DRILLING PERMIT APPLICATION ENVIRONMENTAL HEALTH SERVICES DIVISION SAN MATEO COUNTY DEPARTMENT OF HEALTH SERVICES 2000 ALAMEDA DE LAS PULGAS, SUITE 100, SAN MATEO CA 94403 VOICE (650) 372-6200 FAX (650) 627-8244 ALLOW FIVE (5) WORKING DAYS FOR PROCESSING PERMIT ALL DRILLING MUST BE SCHEDULED WITH COUNTY STAFF AT LEAST THREE (3) WORKING DAYS IN ADVANCE r::U\~N MATEO COUNTY -.nW'.RONMENTAL HEA1.nt NOV - 5 2009 RECEIVED v~ ~~rlS-' Consultant Company: ~K C Primary Contact: ,,)g.;fl(l..~ - F;;;u.. b~ Mailing Address: 105 ClvrL~ Avp, City, State, ZIP:.jy;lJlAn fit J1 J// ~tJ) ~If Telephone: (tJ~O-J ~Bo oj ~6o~ Email: GENERAL CONDITIONS: 1. Only GEOTECHNICAL investigations will be performed under this permit. Other investigations including, but not limited to, environmental investigations and grab soil or water sampling for activities other than geotechnical investigation, require a separate Subsurface Drilling Permit Application with the appropriate fee. 2. Any well installations, including wells for geotechnical investigations, require a separate Subsurface Drilling Permit Application with the appropriate fee. 3. Written notification to Groundwater Protection Program (GPP) staff, on GPP-supplied forms, must occur at least three (3) working days prior to each drilling event. 4. An accurate & correct map of proposed boring locations must be included with the written notification. The . boring location map must be to scale and include north arrow, existing site features, approximate property lines and any other pertinent existing & historic features and information. 5. Boring construction and destruction under this permit is subject to the Standards for the Construction of Wells in San Mateo County, County Groundwater Protection Program (GPP) Guidelines, Policies & Procedures, the State Water Well Standards, and any instructions by County GPP staff. 6. All borings must be properly destroyed (grouted/sealed), using neat cement grout or sand cement (as specified in California Well Standards), within 24 hours of drilling unless special conditions are approved in writing as part of this permit. 7. Drilling under this permit must be under the supervision of a California Professional Geologist or Civil Engineer. 8. If contamination is discovered during drilling, verbal notification to County GPP by the Responsible Professional is required within 72 hours of discovery. A written report is required within 30 days. 9. The consultant company named above assumes responsibility for all activities and uses under the permit, including compliance with Workmen's Compensation Laws, and indemnifies, defends and saves the County of San Mateo, its' officers, agents and employees, free and harmless from any and all expense, cost, or liability in connection with or resulting from work or stopped-work associated with the permit, including, but not limited to, property damage, personal injury, wrongful death, and loss of income. 10. Permit is valid for one calendar year only from the permit issue date. 11. Violation of any requirement or general or special permit condition as listed on this permit application or on the ANNUAL GEOTECHNICAL PERMIT DRILLING NOTIFICATION may result in an order by GPP staff to cease work under this permit and correct the violation. ( one annlication ner office location) Responsible Professional's Signature Responsible Professional's Name Professional Geologist (PG) or Civil/Geotechnical Engineer (CE/GE) No. GPP Staff Approval; @.1/)~, Ce./ Revised evelY January} J ~_... Date: \ ( ., b- O!\