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WELL PERMIT APPLICATION ALPINE COUNTY HEALTH DEPARTMENT 75-B Diamond Valley Road Markleeville, CA 96120 (530) 694-2146 (530) 694-2252 fax PLEASE COMPLETE APPLICATION, SIGN, DATE AND RETURN TO THIS OFFICE WITH APPLICABLE PERMIT FEE OF PROPERTY INFORMATION: Property Mailing Address City, State & Zip Code Assessor’s Parcel Number Property Well Driller Information: Well Contractor License Business Address City, State & Zip Code WELL INFORMATION: TYPE OF WORK: ___New Well ___Repair/Modification ___Destruction ___Proposed Depth_________ft USE: ___Domestic ___Irrigation ___Industrial ___Test Well ___Municipal ___Other: EQUIPMENT: ___Rotary ___Cable Tool PROPOSED CASING: ___Steel ___PVC ___Diameter ___Wall or Gage PROPOSED SEALING ZONES: SEALING MATERIAL: PROPOSED PERFORATIONS/SCREEN: From____to____Feet Neat Cement From____to____Feet From____to____Feet Cement Grout____ From____to____Feet From____to____Feet Bentonite Clay___ From____to____Feet METHOD OF SEALING: Pressure sealed by pumping ___YES ___NO DATE OF WORK: I hereby agree to comply with all regulation of the Alpine County Health Department and with all ordinances, laws of Alpine County and the State of California pertaining to well construction, repair, modification and destruction. Immediately upon completion of work I will furnish the Alpine County Health Department with a complete and accurate well log. WELL DRILLER’S SIGNATURE: DATE: APPLICANT’S SIGNATURE: DATE: County Use: WELL PERMIT (Valid for twelve (12) months from Date of Issue) VERIFICATION OF CONTRACTOR’S FEE PAID ON RECEIPT This certifies that permission is hereby granted to TO INSTALL THE ABOVE WELL in accordance with the above application. Environmental Health Specialist CERTIFICATE OF Environmental Health Specialist (WHEN SIGNED BY HEALTH OFFICER, THIS APPLICATION IS A PERMIT)