Fillable SEPTIC SYSTEM CONSTRUCTION PERMIT APPLICATION (Contra Costa Health Services)

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SEPTIC SYSTEM CONSTRUCTION PERMIT APPLICATION (Contra Costa Health Services)

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Country of origin: US
File type: PDF

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ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 FAX (925) 608-5500
www.cchealth.org/eh
SEPTIC SYSTEM CONSTRUCTION PERMIT APPLICATION
Incomplete Applications will be rejected – please mark all check-off boxes as applicable.
Type of Work Type of Building Projected Sewage Flow Water Supply
New Conventional w/ Design Plan (12) Single-Family Dwelling No. of Bedrooms
New Alternative w/ Design Plan (15) Multiple-Family Dwelling No. of Employees
Minor Repair (28) Commercial No. of Seats
Repair/Alteration (19) Industrial Other
Alternative Replacement (20) Other
Off-site Public Water
On-site Public Water
Name of Supplier
Private Well
Conventional Replacement (14) Number of Wells
Abandonment (21)
Tank Replacement (includes Abandonment) (25)
Conventional DESIGN REVIEW ONLY (42)
Alternative DESIGN REVIEW ONLY (43)
Other
PLOT PLAN REQUIRED – Refer to the Health Officer Regulations for Sewage Disposal
PLEASE PRINT CLEARLY. *REQUIRED FIELDS MUST BE COMPLETED
THE APPLICATION IS NOT THE PERMIT. SUBMIT FOUR SETS OF PLANS.
*Legal Owner’s Name
*Legal Owner Address
*Owner Email Address:
*City/ State/ Zip
Country
*Owner Telephone
*Owner Billing Address (if different from above)
Site Address/ City/ State/ Zip: (if different from above):
Subdivision/Minor Subdivision #
*Contractor:
Lot/Parcel #
*Contractor Contact Person:
*Email Address:
*Contractor’s Address/ City/ State/ Zip Code:
*Contractor’s License #
*Contact Person’s Telephone #:
*Plan Design by:
*Designer’s Name:
*Designer’s Telephone #:
*Plan Designer’s Address/City/State/Zip Code:
*Email Address:
I hereby certify that the above information and submitted plans are true and correct and that the proposed work will comply with all permit conditions and applicable laws and regulations. I
agree to obtain all required inspections, maintain a copy of the approved permit and plans at the job site until final approval, and obtain written authorization prior to deviating from the
approved permit or plans, or placing the system in service. The issuance of this permit by Contra Costa Environmental Health Division does not guarantee a satisfactory or an indefinite
operation of any septic system.
Signature of Owner or Agent Date
Signature of Designer or Contractor Date
FOR OFFICE USE ONLY
FA#
ON#
SR#
P/E:42
Census Tract:
REHS:
Supervisor:
Amount Due:
Amount Paid:
CASH / CC: MC VISA
Check #
Date Received:
XR:
Initial:
Date Approved:
CONDITIONS:
Revised 10.15.19
Y:FORMS-INFORMATION/Land Use/Applications/Septic System Construction Permit Application
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SEPTIC SYSTEM CONSTRUCTION PERMIT APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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