Full Text
Submit application and attachments to: Well Permits 201 S. Anaheim Blvd., Suite 1101 Anaheim, CA 92805 [EMAIL REDACTED] Anaheim Public Utilities Well / Boring Permit Permit Number UWP- Soil Boring / Vapor Probe Geotechnical Environmental Other Soil borings or vapor probes deeper than 20 feet, or that extend into groundwater regardless of depth require a permit. Well Installation Water Supply Cathodic Protection Environmental Other Injection Injection wells (including stormwater "dry" wells) must be registered with EPA. Include documentation of registration with permit submittal. Well Destruction Water Supply Monitoring Other Applicant Driller Company Company Contact Address Address City State Zip City State Zip C-57 License and Exp. Email Phone Well Location Well / Boring Owner Address, Cross Street, or Description Company (Include scaled site plan with permit submittal.) Contact Address City State Zip Located in City right of way (requires Public Works permit) Phone Scope of Work. Include installation or construction methods including seal type and placement. Soil cuttings may not be used for boring backfill. Attach additional pages if necessary. Well / Boring Details (Attach additional pages if necessary.) Well / Boring Name Name Type Boring Diameter (inches) Casing Diameter (inches) Depth (feet) Screen Intervals (feet) I hereby agree to comply with all ordinances, rules and regulations of the Required Attachments: City of Anaheim and the State of California pertaining to well construction All Applications: Site plan including roads, sewers, surface water, and destruction. I attest that I am authorized to sign on behalf of the and possible sources of contamination within 200 feet of well site. property owner and/or well owner. Well Installation Applications: Vertical diagram detailing depths, sizes, and thicknesses of well casing, annular seal, and screens. Include pertinent geological features. Signature Date Anticipated Drilling Start Date Well Destruction Applications: Well construction logs. Approvals Approved Subject to the following conditions: NOTIFY THIS AGENCY AT LEAST 48 HOURS PRIOR TO START Email [EMAIL REDACTED] Submit boring log and coordinates (WGS84) to this Department within 60 days of completion. Reference permit number. Driller must submit Well Completion Report to CA Dept. of Water Resources. Secure all wells to prevent tampering. Other Administrative Use Only Permit Issued By: Print Name Date Well inspected by: Print Name Date Phone Email Anaheim Business License # and Exp. Rev 10/2025 ---PAGE BREAK--- Payment Contact Company Contact Email Anaheim Public Utilities Well / Boring Fees Address City Phone Permit Number UWP- State Zip Payment Type Please include a check payable to "City of Anaheim" Check Number Check Date Required Fees All permits must include an application fee. Well installations and destructions are an additional $86 per well. There is no per-well fee for vapor probes. Well Installation Number of Wells x $86 = $ Well Destruction Number of Wells x $86 = $ Soil Boring Application Fee + $0 + $282.75 Total = $ Administrative Use Only Fees Received By: Name Date P/C Fund Dept Unit Rev Src WO [PHONE REDACTED] 3049