Fillable SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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File type: PDF

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Revised 2.24.17
Y:FORMS-INFORMATION/Land Use/Applications/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
SHALLOW HOLE NOTIFICATION APPLICATION
FOR USE BY ANNUAL SHALLOW HOLE PERMIT HOLDERS ONLY.
THIS IS NOT A PERMIT APPLICATION
ONE APPLICATION PER PARCEL. GEOTECHNICAL BORINGS FOR NON-INDUSTRIAL SITES ONLY
ENVIRONMENTAL HEALTH STAFF MUST BE NOTIFIED AT LEAST 2 WORKING DAYS PRIOR TO DRILLING
PLEASE PRINT CLEARLY. *REQUIRED FIELD MUST BE COMPLETED. THIS IS NOT A PERMIT
LEGAL OWNER
INFORMATION
*Legal Property Owner/Boring Owner
*Address
Phone Number:
*City
State
Zip code
*Property owner name (if different from Boring Owner)
Address/ City/ State/ Zip Code
SITE
INFORMATION
*Site Name:
*Address:
*City/ State/ Zip code
Lot/Parcel Number:
*On-site Contact Name:
*On-site Contact Cell Number:
LICENSED DRILLER INFORMATION
*Business Name:
*Contact Name:
*Business Phone:
*Mailing Address:
*C-57 License #:
Email Address:
CONSULTANT/ENGINEER INFORMATION
*Business Name:
*Contact Name
*Business Phone:
*Mailing Address:
Email Address:
*CONSTRUCTION/DESTRUCTION SPECIFICATIONS*
DATE OF DRILLING:
Number Geotechnical Borings:
Boring Depth (b.g.s.):
Type of Material for annular seal/destruction (specify mix or product):
Bentonite Concrete Cement
**(Bentonite chips for transition seal only)**
Method of Drilling/Destruction/Other:
PLOT MAP RIGHT OF ACCESS AGREEMENT
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 notification and plans at the job site until, and obtain written authorization prior to deviating from
the approved notification application or annual shallow hole permit conditions.
_________________________________________________________ ______________________________________
Signature of Annual Shallow Hole Permitee Date
FOR OFFICE USE ONLY
FA #:
P/E:
4307
WP#
DATE RECEIVED:
REHS:
SUPERVISOR:
AMOUNT DUE: $
AMOUNT PAID: $
CHECK #:
CASH CREDIT CARD:
MC
VISA
XR
INITIAL:
DATE APPROVED:
CONDITIONS
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SHALLOW HOLE NOTIFICATION APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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