Fillable WELL PERMIT APPLICATION (Contra Costa Health Services)

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WELL PERMIT APPLICATION (Contra Costa Health Services)

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Revised 2.24.17
Y:FORMS-INFORMATION/Land Use/Applications/Well Permit 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
WELL PERMIT APPLICATION
APPLICATION FEE IS NON-REFUNDABLE (SERVICE FEES ARE ADDITIONAL REFER TO FEE SCHEDULE)
ONE APPLICATION PER WELL
TYPE OF WORK: SEWAGE DISPOSAL:
Domestic Water well (69) _____ Well Destruction (68) _____ Dewatering Well (51) # of____ Septic System
Monitoring well (65) _____ Piezometer w/ casing (67) _____ Public/Small Water System Well (63) Industrial Well (73) Sewer System
Well Reconstruction (69) _____ Flow Test (99) Agricultural/Irrigation Well (72) Other________
PLEASE PRINT CLEARLY. * REQUIRED FIELD MUST BE COMPLETED (Attach plot plan and safety plan, as needed)
LEGAL OWNER
INFORMATION
*Legal Owner:
*Address:
Phone Number:
*City:
State:
Zip code:
*Billing Address (if different from above):
SITE
INFORMATION
*Name (if different from owner address):
*Address (if different from owner address):
*Assessor’s Parcel Number:
Subdivision/Minor Subdivision #:
Lot/Parcel Number:
*On-site Contact Name:
*On-site Contact Cell Number:
LICENSED DRILLER INFORMATION
*C-57 License Number:
*Business Phone:
*Email Address:
*Fax Number:
CONSULTANT/ENGINEER INFORMATION
*Business Phone:
*Fax Number:
Email Address:
*CONSTRUCTION/DESTRUCTION SPECIFICATIONS*
Well Casing Diameter
Casing Material
Gauge
Annular Seal Depth **
Borehole Diameter
Boring Depth (b.g.s.)
Annular Seal Thickness
Gravel/Sand packed
Conductor Casing
Conductor Casing Depth
Method of Drilling/Destruction/Other:
Type of Material for annular seal/destruction (specify mix or product):
Bentonite Concrete Cement **(Bentonite chips for transition seal only)**
VARIANCE REQUIRED – attach Variance form with fee. One form per job. **
Required for water well and monitoring well annular seals that are less than 50 feet and 10 feet below ground surface (b.g.s.), respectively.
PLOT MAP HEALTH & SAFETY PLAN ENCROACHMENT PERMIT (If in right of way) RIGHT OF ACCESS AGREEMENT
PERFORMANCE BOND REQUIREMENT: Contra Costa County Ordinance, Title 4 Health and Safety, Article 414-4.10; Section 414-4.1023(a) Prior to the issuance of a permit, the
applicant shall post with the health officer a cash deposit or bond guaranteeing compliance with the terms of this chapter and the applicable permit, such bond to be in an amount deemed
necessary by the health officer to remedy improper work but not in excess of five thousand dollars.
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 well in service. The issuance of this permit by Contra Costa Environmental Health Division does not guarantee a satisfactory and an indefinite
operation of any well system.
_________________________________________________________ ________________________________________
Signature of C-57 Licensed Driller Date
FOR OFFICE USE ONLY
FA #:
PR #
P/E:
43
CT #:
DATE RECEIVED:
REHS:
SUPERVISOR:
AMOUNT DUE: $
AMOUNT PAID: $
CHECK #:
CASH CREDIT CARD:
MC
VISA
XR
INITIAL:
DATE APPROVED:
CONDITIONS
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WELL PERMIT APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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