Fillable ANNUAL PERMIT FOR SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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ANNUAL PERMIT FOR SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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Revised 2.24.17
Y:FORMS-INFORMATION/Land Use/Applications/Annual Permit for Shallow Hole Notification Application
CONTRA COSTA COUNTY
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD CA 94520
Phone (925) 692-2500 Fax (925) 692-2502 www.cchealth.org/eh
ANNUAL PERMIT FOR SHALLOW HOLE NOTIFICATION APPLICATION
Allow three working days for processing. All drilling conducted under this permit must be preceded by a Shallow Hole Notification Application
submitted to this Division at least 2 business days prior to commencement of drilling activity
. One application per consultant/engineer office location.
General Conditions:
1. Only GEOTECHNICAL investigations may be performed under this permit. Borings may not exceed 20 feet in depth. Other
investigations including, but not limited to, environmental investigations, grab soil or water sampling, or any activities other
than geotechnical investigations, require a Soil Boring Permit Application with the appropriate fees.
2. A Shallow Hole Notification Application must be submitted with the appropriate fee at least two (2) business days prior to
each drilling project.
3. Borings conducted under this permit must be properly destroyed (grouted/sealed) in a manner approved by Contra Costa
Environmental Health.
4. Borings conducted under this permit must be under the supervision of a California Professional Geologist or Civil
Engineer.
5. If contamination or groundwater is encountered during drilling, the Responsible Professional is to notify Contra Costa
Environmental Health staff prior to destroying the boring and submit a Soil Boring Permit Application with the appropriate
fees.
6. Any well installations, including wells for geotechnical investigations, require the submission of a separate Well Permit
Application with the appropriate fee
7. Permit is valid from date of issuance through December 31 of the same year. Permit fees are not prorated and are non-
refundable.
CONSULTANT/ENGINEER INFORMATION
*Business Name:
Primary Contact:
Business Phone:
*Mailing Address:
Email Address:
Responsible Professional’s Name:
Responsible Professional’s Signature:
FOR OFFICE USE ONLY
FA #:
PR #
PE 4305
DATE RECEIVED:
REHS:
SUPERVISOR:
AMOUNT DUE: $
AMOUNT PAID: $
CHECK #:
CASH CREDIT CARD:
MC
VISA
XR
INITIAL:
DATE APPROVED:
CONDITIONS
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ANNUAL PERMIT FOR SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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