CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
925-608-5500 FAX 925-608-5502
www.cchealth.org/eh
LAND USE PLAN REVIEW APPLICATION
Mark Check-off Boxes as Applicable for Type of Work
Type of Work Type of Structure Projected Sewage Flow Water Supply
❑ New Structure with Plumbing Fixtures (40) ❑ Single-Family Dwelling ❑ No. of Bedrooms _______ ❑ Off-site Public Water
❑ Addition/Remodel (40) ❑ Commercial ❑ No. of Employees _______ ❑ On-site Public Water
❑ Structure – No Plumbing Fixtures (41) ❑ Barn ❑ No. of Seats _______ ❑ Name of Supplier_____________
❑ Other (40 / 41) ❑ Solar ❑ Other _____________________ _____________________________
❑ Other _________________ ❑ Private Well
Number of Wells ______________
FOUR SETS OF PLANS REQUIRED FOR PLAN REVIEW
PLEASE PRINT CLEARLY. ALL FIELDS MUST BE COMPLETED. INCOMPLETE APPLICATIONS WILL BE REJECTED
Owner Billing Address (if different from above)
Site Address (if different from Owner)
Contractor or Agent Contact Name
Contractor or Agent Address/ City/ State/ Zip Code
Contact Person’s Telephone
I hereby certify that the above information and submitted plans are true and correct and that the proposed work will comply with all applicable laws
and regulations. I agree to obtain written authorization prior to deviating from the approved plans.
_____________________________________________________________ _________________________________________________________________
Signature of Owner or Agent Date Signature of Contractor Date
FOR OFFICE USE ONLY
Plan Check (PE 4240 or 4241)
Amount Paid: $ ________________
Check #: CASH / Credit Card: MC___ VISA___
Land Use Plan Review (July 2019)
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
