Fillable Well-permit-application CITY OF LONG BEACH

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Well-permit-application CITY OF LONG BEACH

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U.S.A. forms for City of Long Beach California

BROWSE CITY OF LONG BEACH CALIFORNIA (CA) FORMS

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1 Rev. 10.23.19
WELL/BORING PERMITTING
Well(s), as defined in the California Well Standards, bulletins 74-81 and 74-90, must have a
permit for both construction and/or destruction/abandonment of wells. A permit is also required
for soil boring(s). The permit must be on site at the time of drilling and produced upon request
of the inspector.
Well Permit Applications may also be obtained from the Health Department at 2525 Grand
Avenue, Room 220 Monday through Friday from 8:00 a.m. to 4:30 p.m. The permit must be
completed, signed and returned. Allow 10 business days for well permit review and
processing. Please make all checks payable to the City of Long Beach, Department of
Health and Human Services.
In addition to the completed permit, the following information is required:
1. A Department of Public Works Excavation Permit is mandatory for the
construction/destruction of any well in the public right-of-way. Call the Franchise
Supervisor at (562) 570-6530 for a permit application or write to:
Department of Public Works
411 W Ocean Blvd., 5
th
Floor
Long Beach, CA 90802
Attention: Franchise Supervisor
2. Plot plan locating each well to be constructed or abandoned.
3. Distance from existing wells and utility lines.
4. Construction schematic of well(s), including depths and diameter.
5. Mail in drillers log at completion of project.
6. Current fees for well(s)/boring(s) are:
a. Soil Boring $ 435.00 per site
b. Construction of drinking water well(s) $ 470.00 per well
c. Construction of monitoring/Sparging well(s) $ 330.00 per well
d. Well abandonment/destruction $ 435.00 per well
e. Cathodic Well $ 540.00 per well
f. Vapor Extraction $ 330.00 per well
g. Expedite fee (permit available within 3 business days) double per well/site price
h. Late fee (applied less than 10 business days) double per well/site price
Fees are subject to change without notice. Contact inspector at least 48 hours prior to drilling so
arrangements can be made for inspection of each well prior to the sealing of the well(s).
Health and Human Services Department
Bureau of Environmental Health
CPP – Water Quality Program
2525 Grand Avenue #220, Long Beach, CA 90815
Office (562) 570-4132 | Fax (562) 570-4038
2 Rev. 10.23.19
WELL PERMIT APPLICATION
Date: _____________________________________ Proposed Drilling Date: ____________________________________
Site Address:_________________________________________________________________________________________________________
Permit Delivery: Mail Fax Pick Up E-mail:_______________________________________________
Permit Type: New Well Construction Destruction Other: _____________________________________
Well Type: Monitoring Cathodic Private Domestic Public Domestic Vapor Extraction
Soil Boring Sparging Number of: Wells ___________ Borings_____________
Well Owner Name:________________________________________________________ Phone:_________________________________
Well Owner Address:_______________________________________________________________________________________________
City State Zip Code
Consulting Firm Name:___________________________________________________ Phone:_________________________________
Consulting Firm Address: __________________________________________________________________________________________
City State Zip Code
Drilling Company Name:_________________________________________________ Phone: _________________________________
Drilling Company Address:_________________________________________________________________________________________
City State Zip Code
CA License #:___________________________________
PROVIDE PLOT PLAN LOCATING EACH WELL CONSTRUCTED OR ABANDONED
C
ONSTRUCTION
/D
ESTRUCTION
M
ETHOD
Type of casing, method of sealing etc., (Use additional sheet or attachments)
I hereby agree to comply in every respect with all regulations of the Long Beach Department of Health and Human Services and with all ordinance and laws of the
City of Long Beach and of the State of California pertaining to well construction, reconstruction and destruction. Upon completion of well and within ten days
perforations in casing, and any other data deemed necessary by other city agencies.
Print Name: ______________________________________ Applicants Signature:_________________________________________
Telephone:___________________________ Fax Number:__________________________ E-mail:_____________________________
FOR OFFICE USE ONLY
□ Approved □ Denied Well Permit # __________________ Approved by:__________________________________ Date: _________________
□ Approved with Conditions (indicate conditions here incl) ________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
Health and Human Services Department
Bureau of Environmental Health
CPP – Water Quality Program
2525 Grand Avenue #220, Long Beach, CA 90815
Office (562) 570-4132 | Fax (562) 570-4038
E
XPEDITE
(FEE’S APPLY; SEE PG. 1)
Permit # ______________
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Well-permit-application CITY OF LONG BEACH

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Completed 13 July 2020

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