CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 692-2500 (925) 692-2502FAX
www.cchealth.org/eh
SITE & SOIL EVALUATION APPLICATION
Mark Check-off Boxes as Applicable for Type of Work
Type of Work Type of Building Projected Sewage Flow Water Supply
❑ Site Evaluation (30) ❑ Single-Family Dwelling ❑ No. of Bedrooms _______ ❑ Off-site Public Water
❑ Soil Profile Evaluation (33) ❑ Multiple-Family Dwelling ❑ No. of Employees _______ ❑ On-site Public Water
❑ Percolation Test w/ contractor (38) ❑ Commercial ❑ No. of Seats _______ ❑ Name of Supplier_____________
❑ Industrial ❑ Other _____________________ _____________________________
❑ Other _________________ ❑ Private Well
Number of Wells ______________
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. (NOTE: Percolation tests are valid for five (5) years).
_____________________________________________________________ _________________________________________________________________
Signature of Owner or Agent Date Signature of Contractor Date
FOR OFFICE USE ONLY
❑ Site Evaluation (PE 4230)
Amount Paid: $ __________
Check #: CASH / Credit Card: MC___ VISA___
Amount Paid: $ __________
Check #: CASH / Credit Card: MC___ VISA___
❑ Percolation Test (PE 4238)
Amount Paid: $ __________
Check #: CASH / Credit Card: MC___ VISA___
Site & Soil Evaluation (July 2019)
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