HomeMy WebLinkAboutMUP24-0001 Septic PacketMOFC#
SEPflRfiTOR
Butte County Department of Public Health
DIVISION OF SANITATION
Septic Tank System Inspection Certificate
H\70
Vl-
^.695 OLEANDER AVENUE
CHICO,CALIFORNIA
343-421 1,EXT.62
2430 BIRD STREET
OROVILLE,CALIFORNIA
533-1230,EXT.297
O:I
a
The Septic Tank System was Installed at
FOR
SEPTIC TANK
Length
Width
Water Depth
Material c^<?S-^
The above dimensions meet the minimum requirements of County Ordinance.No.699.Additional leachingareawillberequiredifexperienceshowsittobenecessary.^
LEACHING FIELD
Length ..SQ^.
Width
....ft.....ft.A ^_ft.in.EZft.No.of Lines ......
Rock Under Tile in.
REMARKS:
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SANITARIAN
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70(>v BUTTE COUNTY DEPARTMENT OF PUBLIC HEALTH
DIVISION OF SANITATION e ;
SEWAGE DISPOSAL PERMIT695OLEANDERAVENUE
CHICO.CALIFORNIA 95926
Phone:343-4211,Ext.62
2430 BIRD STREET
OROVILLE,CALIFORNIA 95965
Phone;533-1230,Ext.297
3DateIssued
EXPIRES ONE YEAR FROM DATE OF ISSUANCE
rRjOl/iOPermitIssuedto
77 T)S ^0 ^o/7-/y!
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To construct a sewage disposal system for:
Located at::2ai
SEPTIC TANK SYSTEM REQUIREMENTS
Septic Tank(Inside Measurements)Leaching Field
32Length:...
Width:...
Liquid depth:
Liquid capacity:
ft.Total Length:
Trench width:
ft.
ft.inches
5ft.Minimum No.of lines
/006 0Rockundertile..gals...inches
Special conditions:77n/9MMS -
Additional leaching field will be required if experience shows it to be necessary.No part of the system maybelocatedwithin50feetofthecenterlineofanyCountyRoad.
NOTE:Satisfactory inspection by the Health Department iis required before backfilling or puttingthesystemintouse.Occupancy of a new building is not permitted until the system is approved.
Permit Fee S ;Penalty Fee $Total Fee S
>Building Sewer Fee S Issued By:SanitarianIdReceiptNo
S3 1 -1 1 62 R
IW.^y H 0 1973
It
4.
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r S'^(c>Butte County Department of Public Health ■>)
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695 01«and«r Ave.
CHICO.CALIFORNIA 95926
3<13.4211 :EXT.62
2430 BIRD STREET
OROVILLE,CALIFORNIA 95965
533.1230:EXT.297
DIVISION OF SANITATION
APPLICATION FOR PERMIT TO CONSTRUCT A SEWAGE DISPOSAL SYSTEM
:3mWL£..^.
Applicant’s Name:
Mailing Address:
533-^870Phone
Name of Owner:
,r^M3D£ 1.Construction sice:
(STREET a NUMBER OR DIRECTION ft DISTANCE TO NEAREST CROSSROAD!
ft.X2.Lot size:ft.;.acres
3.Application for new system for new building]Q ;
Repair of or addition to old system □>
auxiliary or secondary system Q ;
New system to replace existing sewage disposal facilities
4.Type of building to be served by proposed system:
No.Bedrooms.^ HOME □No.Baths?'Garbage GrinderQ YesQ
£/S££...£.£.S.ZKOTHEiypn(Specify)
5.Water supply for premises:Communityn ;Private weIlQT*Other
Water supply for adjoining properties:
Other ,
Communityn i Private Well*Xi i
*If private well,how many feet from your nearest property line?.ft.
6.SCALE PLOT PLAN TO BE FURNISHED:
Sketch to scale on reverse side hereof,or attach scale sketch of plot plan of the premises showing:
a)Property lines,
b)Location of proposed building and driveway,
c)Location of large trees,rocks,or ocher obstacles,
d)Location of any well,spring,creek or other body of water,
e)Show direction and approximate amount of slope.
I hereby state that the information above and on the revere sy^e hereof or attached hereto is correct and truetothebestofmyknowledge.I understand that the permit musi h^obtained bcfoc^any construction is begun eitheronthebuildingoronthesewagedisposalsystem,and chac|a/^tisfa(^cory in spec^n of the system is required beforethenewbuildingmaybeoccupiedorthesystembackfi
Zoning and access:Ll 0 KQ ;NOKQ];
Denied:..
d,or pu /into ust.
K-Signed:
Cleared by l^lanningPermitissued...!.
Remarks:
By:Date:
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BUTTE COUNTY DIVISION OF ENVIRONMENTAL HEALTH
REQUEST FOR SERVICE
Wei 1SepticDestr.SepticClearance
Pre-Application Rev.Water Sample Plan Check
Other id
AP#Date 7
//f
App1 leant:
Location:
c:^P5 ^Fee:Receipt No.
II8“\
●i S'Comments:
LJ
Contractor/Engineer:Access/Contact Telephone
Name
Mail Report To:
Call for Pick Up:
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Butte CountytnvironmentalHealth,-Jhl^'d/sl._0
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BUTTE COUNTY DEPARTMENT OF PUBLIC HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
SEPTIC SYSTEM INSPECTION CERTIFICATE
7 COUNTY CENTER DRIVE
OROVILLE,CALIFORNIA 95965
Telephone (916)538-7281
7:)///r\
1469 HUMBOLDT ROAD
CHICO,CALIFORNIA 95928
Telephone (916)891-2727
The Sewage Disposal System was inspected at.
FOR LEACHING FIeIlSEPTICTANK
r*>looo Length
Width
No.of lines
Rock Under Pipe
wfeetSizeGallons■*‘7>l v:
inchesMaterial
>●>:r ^v
inches
The above dimensions meet the minimum requirements of Butte County Code,Chapter 19.
Additional leaching area will be required if experience shows it to be necessary.
Remarks:
D.Date:
S2 -778R (Rev.6/94)●ENVIRONMENTAL HEALTH SPECIALIST
I!*!/*Af-f:I ■«.fij'-'i I.-..>1
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BUTTE COUNTY DEPARTMENT OF PUBLIC HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
SEWAGE DISPOSAL PERMIT
'i 411 MAIN STREET ●R O.BOX 5364CHICO.CALIFORNIA 95927TEL:(916)891-2727FAX:(916)895-6512
7 COUNTY CENTER DRIVE
OROVILLE,CALIFORNIA 95965TEL;(916)538-7281FAX:(916)538-2140
i 2--/-T-Date Issued
EXPIRES ONE YEAR FROM DATE OF ISSUANCE
PwO
//■^TS ^Uy\i ^6 sn^ui/L,Oa
S^-iMu 'On>(j>
Permit Issued to
I
To construct a sewage disposal system for:_
Located at:A.P.#
SEWAGE DISPOSAL SYSTEM REQUIREMENTS7
SEPTIC TANK
Liquid capaciW:jOO 0
Material
LEACHING FIELD
Total length:gallons feet
Trench width:inches
SMinimumNo.of lines:
Rock under pipe inches
Special conditions:^f^/F/^Xhpo-ficlTT h^iPillnOC:)srtUiTMYg,.oh'PecU opJ .L7A^V■k)/T//SLuec-yAdditionalleachingfieldwillberequiredifexperienceshowsItto(oe necessary.No part of the system may be located within
AAj\/_c/CaT^^^o^^CQfr\jAT
I
50 feet of the center line of any County Road.
NOTE:Satisfactory inspection by the Health Department is required before backfilling or putting the system into use.Occupancy of a new building Is not permitted until the system is approved.
^DDPermitFee$;Penalty Fee $:TOTAL FEESI
Additional Fee $
Receipt No.,(k(j.l ENVIRONMENTAL HEALTH SPECT/^ST
JtIssuedBy:
S31 -278R (Rev.6/94)
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BUTTE COUNTY DEPARTMENT OF PUBLIC HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
●1
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7 County Center DriveOroville.CA 95965TEL:(916)538-7281FAX;(916)538-2140
411 Main Street
PO.Box 5364
TEL:(916)891-2727FAX:(916)895-6512
APPLICATION FOR PERMIT TO CONSTRUCT A SEWAGE DISPOSAL SYSTEMSa./^or\‘_l3c?-Z u %^r^^hnnp
^rOU<f//t /Ji^70 f /)f^arJuJOoJanddistancBlonearestcrossroad'7 7/WA -q^lf
Auxiliary or secondary system □New system to replace existing facilities □
sessor’s Parcel No 0^%-^OQ-'OC\Cs»Owner’s Name
Applicant’s Name_/"p,<0.£ojc ^-7^^/^2-S//^7sr Mv/yp(Street an^umber or direction
Mailing Address
1.Construction Site
il2.Lot Size.ieet X
3,APPLICATION FOR:New system for new buildingRepairoforadditiontooldsystem □
feet.acres
c*%
'4.Type of building to be served by proposed system:
Mobile Home
House
Other
5.Water supply for premises:(Must be safe,potable water)Community □Private well 0^Other
Water supply for ajoining properties:
6.WORKMEN'S COMPENSATION INSURANCE
3’STlsize -^Garbage disposal?^^^J No.Bedrooms
□No.Bedrooms
□(specify)
Garbage disposal?
Community □Private well 0^Other
0^have placed on file with the County of Butta a cortlllcata ol Workman'sCompensationInsurance.
D I canily that In the perlormsnce ot the work tor which this permit IsIssuedIshallnotemployanypersonInanymannersoastohecomesubjecttotheWorkman's Compensation Laws of Calllornla.
I am aware ot the provisions ol Section 3700 ot the California Labor Code.Which requires every employer to be Insured against liability for Workmen'sCompensation.
7.SCALE PLOT PLAN TO BE FURNISHED
Sketch to scale on reverse side hereof,or attach scale sketch of plot plan of the premises showing:
e.Show direction and approximate amount of slope,
f.Source of water,
g.Water lines.
●h.Set back lines and easements,
i.Proposed sewage disposal system and area for
replacement.
I hereby state that the information above and on the reverse side hereof or attached hereto is correct andtruetothebestofmyknowledge,I understand that the permit must be obtained before any construction isbeguneitheronthebuildingoronthesewagedisposalsystem,and that a satisfactory inspection of the systemisrequiredbeforethenewbuildingordwellingmaybeoccupiedorthesystembackfilled,or put into use.I alsounderstanc^at a safe potabl^ater must be supplied to the new building or dwelling before occupancytakeplac
a.Property lines,
b.Location of all proposed and existing buildings,structures,driveways and parking areas,
c.Location of large trees,rocks,or other obstacles,
d.Location of any well,spring,creek or other body ofwaterontheparcelandwithintOOfeetofpropertyline.
canZSigned
Date
Owner □Authorized agent Licensed contractor □
.(An original letter of authorization must accompany this application in order foranauthorizedagenttosign.)6*
FOR OFFICE USE ONLY
^Q.7-^^
Potable water
'WLegal parcel? Access
Water plans clearedComment
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Zonin
Rcpt,Usepermitted? Amount
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BUTTE COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
7 County Center Drive
Oroville,California 95965
530-7281
l’96 Mi/morial WayLChico,California 95926.jyii^-2727 ^
747 Elliqtt Road ^Paradise,California'95969:;^
872-6308'L~:V
II
APPLICATION AND PERMIT T>GONSTRUCT OR DESTROY A WELL
Individual Well Q
□Repair or Deepen
Well Destruction □I Application for:Public Water Supply
Type of Construction:□New Construction j
Owner's Name:Assessor's Parcel No.7
(916)589-3914SonDrillingCO.David aApplicant's Name:
Mailing Address:_
Site Location:
Phone No.,
Oroville,CA.95965P.O.Box 1029
T,R.S.
SKETCH ON HOW TO LOCATE PROPERTY
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WORKMEN'S COMPENSATION INSURANCE I have placed on file with the County of Butte a certificate ofWorkmen's Compensation Insurance.BIamawareoftheprovisionsofSection3700oftheCaliforniaLaborCode
Which requires every employer to be insured against liability lor Workmen's Compensation,I certify that in the performance of the work for which this permitisissuedIshallnotemployanypersoninanymannersoastobecomesubjecttotheWorkmen's Compensation Laws of California.
COMPLETE FOR NEW CONSTRUCTION
David and Son Drilling CO.425609Driller's Name;Well Driller Contractors License Number.
P.O.Box 1029 Oroville,CA.Driller's Address:Proposed Depth
COMPLETE FOR WELL ABANDONMENT
Proposed Usage.
Name of individual responsi'ble for work;
Address:
Scale Plot Plan is to be furnished on reverse sides of both applications,
I hereby state that the information above and on the reverse side hereof or attached hereto is correct and true to the best of my knowledge.
I understand that the permit must be obtained before any construction is begun,I further state that I am Q the owner of the property,G the owner's authorized representative,m a Licensed Vslell Drilling Contractor
Date:Signed;
c
s~J -7^"—
T7PERMIT/7SFeereceived:
/To be completed by the Health Department.
Permit to Begin Work Approved by Receipt No.:
Date Issued
Expires one year from date of issuanceAdditionalPermittoDestroyDryHolePriortoSiteAbandonment□
Special Conditions
1.Provtde a minimum twenty-four (24)hour notice prior to installing or placing sanitary seal or drilling a well expected to be completed in less than^^^^snty-four (241 hours.
2.A saiislactory inspection by the Health Department and receipt by the Health Department of a Driller's Report or a satisfactory abandonment report and adisinfectionstatementisrequiredforfinalapprovalofwork■.r
Copy 1 -Applicant
Copy 2 ●Health Department Zone &Req SB.
Pci.Status f
PREPARE IN DUPLICATE
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QUADRUPLICATE
Por Local Requirements
Pagfi 1 ofOwner’s Well No..SQal»0418
DWH USE ONLY DO NOT FILL INSTATEOFCALIFORNIA
WELL COMPLETION REPORTi..STATE WELL NO./STATION NO.Refer to Iniiruciion PamphletX
No.563353 i 1 i 15/2.aZ9-5—_,Ended.5/24/95LocalPermif*Agency County Environmantal Health5/9/95
LATrrUOE LONGITUDEDateWorkBegan
II Iii iAPN/TWS/OTHERPermi.t'No.-174B5Q Permit Dale
GEOLOGFC LOG ^W^ELL OWNER —Ray'Taylor V Mailing Addres<;^RQ75 Hlgltvay 70,Orovllle»\CAX95965
ORIENTATION (.£)fi_VERTICAL HORIZONTAL (SPECIFY)
(Ft.)BELOW SURFACE
ANGLE
95DEPTHTOFIRSTWATERDEPTHFROM
SURFACE DESCRIPTION
Deicribe material,j^oin size,color,etc.s'
(
CITY STATE\\\r V.;ZIP\FI.10 Ft.WELL'LOCATION^Dea<ayood ,Rd-;.T
oroville' ‘County Butte j'-s JAPNBookQ^Q^'Vage22N
0 :76 'Brown clay
76 '95 :Broken roclc and cXay-))^C ^
95 :99 :Brovn clav
99 I lie ;Clay and bro^cen^roclc^\^>\118 '163 'Broken broimstained—v\\
::serpentine ^\\V\)]
163 :160 :Seepentine^rock\\\^>^
006Parcel.
Section
Longitude
4B 27Township.^O'v I '●.Latitude
Range
NORTH WEST11j.XDEG.MIN.SEC.
-LOCATION SKETCH
^NORTH
OEG.MIN.SEC.
■j—ACTIVITY (il)—●5_NEW WELL
(-●
c\\\\C'
A \\\MODIFICATION/REPAIR\Xv.\v^V'/
Deepenff\>\\,r ●i \Other (Specity)/*\V //
I I \>
DESTROY (OeaenbeP'oeaduraa anb Uaferiels
Under ■GeOLOGICLOG")
-PLANNED USE(S)-(il)MONITORING
A\VTT
WATER SUPPLY
entot Health X DomesHciinvironiu
Public
JUH 2 9 Irrigelion
■InduBtriel
Otwite.Calitomis "T^STWELL"
CATHODIC PROTEC
TION
OTHER (Speei(y)
SOUTHIllustrateorDescribeDistanceof Well from LandmarkssuchasRoads.Buildtngs,Fences,Aiuers,etc.PLEASE BE ACCURATE 6 COMPLETE.
DRILLING
METHOD Percussion FLUID
WATER LEVEL &YIELD OF COMPLETED WELL
DEPTH OF STATIC
WATER LEVEL 95 (Ft.)&DATE MEASURED
(GPM)&TEST TYPE.
(Hrs.)TOTAL DRAWDOWN
*May voi be Tepreseniative of a 'well's long-term yield.
.25 AirliftESTIMATEDYIELD180TOTALDEPTHOFBORING
TOTAL DEPTH OF COMPLETED WELL
(Feetiso TEST LENGTH (Ft.)
(Feel)
CASINC(S)ANNULAR MATERIALDEPTH
FROM SURFACE DEPTH
FROM SURFACEBORE
HOLE
DIA.
(Inches)
TYPE ItL TYPEINTERNAL
DIAMETER
(Inches)
SLOT SIZEIFANY
(Inches)
GAUGEORWALL
THICKNESS
MATERIAL/
GRADE BEN-CE-z FILTER PACK
(TYPE/SIZE)TONITE FILLMENT5poFl.to Ft.Ft.to Fl.GO o ✓(^)✓
TO XO K 74TO X25psl "0—rro X
F4TO0140 125psiIXSpsl
6 X
F?TO T7HTO140;180 9 siaes6XTT
ATTACHMENTS (^)CERTIFICATION STATEMENT
I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief.■■Geologic Log
Well Construction Diagram
_Geophysical Log(s)
--.Soil/Water Chemical Analyses
Other ■
DAVID S.SON DRILLING CO.NAME (PERSON.FIRM,OR CORPORATION)(TYPED OR PRINTED)
P.0.Box 1029,Oroville,CA 95965
ADDRESS
yy A
CITY STATE ZIP
425609SignedATTACHADDITIONALINFORMATION.IF IT EXISTS.WECl DRILLER/AUTHORIZED REPRESENTATIVE ATE SIGNED C57 LICENSE NUMBER
IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORMDWR188REV.7-90
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PAGE 01DAUIDSSONDRILLII-IG01/30/193&12:24 3165343581
L 1 I 1 JSTATEOFCAUFOHMA^.LL COMPLETION BEPORTRf{er <«r^^riphUi
f
■OUlPUCATe''Driller’,^Copy
of—Ir ^Owner’s Well No.■'
T^l'l HO.;9TA-nON NO.3TATE
IDLlJI563353LONOlTUOEIATfTUOE O'
Ended ●LJL-UJ I,L IDateWork
Local
iAP^L'^
Permit Date V^'i;U 0 W N E RPerlt.OG
Name ^Addressl.a97.3_Hl5U^^-CC-OtXI.1*^^—-9_59.§:i_M r.L i h 0 c.'r (0 N
(SPEr'PTi 70.>t*3Lf
DEPTH OT FlnSl 'Tit*,95_-3EL0‘‘
D»sCRirTK'A
P<i-n‘'y .C'”
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___9L9_l.arasm-clfty-——'.^IXA._Ciity-And^Pcx?ftefl -p.ocK _ftrfTkeG.-£ufOVPi»t.^L0HC..
J i_AAXpAlXtiPfiye7.tan Q<fca*panhLPfl—racJc
viONltCNTiL<<C/LORIENTATION
ZIP3TATECeprvrpOA*eoaMCc c I-
fU ..DftaAifo.ojL Rjl.t
aroytllft-
But.te.—
.058
22H,
F{Ft le Vlidfc*.*'
(l.vr.ock._fl-AdJ6-1 Loai'iN
afn H.«
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2 0i).-PttTtelas^.^iZ<
B.ui^e SecrioriI.Lingit’.ideB3 4Wg3T●iia.h -BT-S£C.MIN..ACTivnv (il —
X_NSW WELl
MOD'F'CATlON/REPAlft
CElirifoLorAIIO*<'i F P'T—-●iToni “●
_Deepen
Omor (Specify)
DESTROY (DeSCflEo |PMe«tfu;es«'id*l«IF''j**;1U,iJ#.--'GfOtO6/Ct.CJ0 )1
-PI,.\.NNED US£|S|-(^)MONITORING
WATER SUPPLY
I.AfTr.^A
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AubliP
__IfflQBllS"
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"TEST WELL"
CATHODIC PROTEiJ'
T!ON ●-other (Speeity).
1
L
Pt ACriPUl-FOM/l£/fc
●^Pll .N'
♦/e.'pjt.tXJiScian
VA ..IP.I i'f L 6
V.'a’-Ih U .Vl'’L.-93 F )i DAlE MEASURED
tSiii/ATED y'i:L.rj'.-23.
TEbi .FN'l'II
?luidiuiuorCOMPLETED WELL
TYPE ift&TESTI
(FO(hfs ’total drawdown
.!hni-UTVt YlCiJ.rOTM ueiTri Or BOiilNC _i30-
TOTAL DCrTH Of COMl'LtTFD WELL
F-f
T8lL f-t ‘1'.p ft \j.-«●.I
aNNVL.aR M.MERIAL(-aSINC.c DEPTHfttCiAJoRFACE
IDEPTHFROMStiRFiCe TYPEeOHF.<f—T-'Ou-
t JMV 4 CE 5Lf{-ImENT TOriJIE.jAUOF
:R WA...
iNT£Hn.‘-L
CHAM*Tr».
I FILTER PAC'K(TYPE/SIZE)Die
jR’.r'FILL(l-'cr'-fl Itt Ft►-.9 {"FJ.Ifr Ff 5 "
0 ■60 X3,,I25pa1.
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.0.^50 'ia._-X^F48QQi4qJ6__X-;.^-f'4aD140-1SQ J_6__^^xl ^.FA80:I I 1 !●,
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nxn I
—CFHTU'ICUION STATEMENT ,
I.thn uiiOetsigned,ceriify lha*this report 'O compictw and accurate to the bej,i of my Knowledge and belr'ct '
UT^CHMENTS {:L)
__GooInfllcLag
Well CarBliuctioii DibO'bPI DAVID &SON DRILLING CO.NAksr tPUtSOfr FIRM.0»CCP“|)P»IICY)(fYVEO OR '‘RltlTJD)Geophysical Lu<j(S)
JBa.Bqx_AQ29a Qrovlllft,CA Q3Qfi«^Sw.l’Wo.,Cnemioal Ano/yyc9 APDfitSS Cirr STATf itfamer
0SignedATTACHADDITIONAL/WF0RMAr»0«,IF IT EXISTS wri IRAUTfiOl
DWRihrev 7 90 IF ADDITIONAL SPACE IS NCEOEO,USc NEXT CONSECUTIVELY NUMBERED FORM
f.●-Gr,
'I BUTTE COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
7 County Center Drive
Oroville,California 95965
538-7281
>1
747 Elliotf-
Paradise,California196MemorialWay
Chico,California 95926
891-2727 87
APPLICATION AND PERMIT TO CONSTRUCT OR DESTROY A WELL
Individual Well ^Well Destruction □Application for;Public Water Supply □
Type of Construction;□New Construction □Repair or Deepen 0‘59-:)ncy-00i
T-Sbnngbx/D3-q hrCK/MlrRl-S Hvoy TQ
Xbc:Assessor's Parcel No.■Owner's Name;
Applicant's Name:
Mailing Address:
Site Location:_
Phone No.
T.R.S.
SKETCH ON HOW TO LOCATE PROPERTY
4w9i=t KMEN'S COMPENSATION INSURANCE 0 I have placed on file with the County of Butte a certificate ofWorkmen's Compensation Insurance.I *
I am aware of.'lhe provisions of Section 3700 of the California Labor CodeWhichrequires'every employer to be insured against liability for Workmen's Compensation.I certify that in the performance of the work for which this permitisissuedIshallnotemployanypersoninanymannersoastobecomesubjecttotheWorkmen's Compensation Laws of California.
COMPLETE FOR NEW CONSTRUCTION
bfiller's Name
?Ci6s)x iP;^Pro Ch Well Driller Contractors License Number.
Proposed Proposed UsageDriller's Address:
b.
COMPLETE FOR WELL ABANDONMENT0
{Marne of individual responsfble for work:
Address::
Scale Plot Plan is to be furnished on reverse sides of both applications.
I hereby state that the information above and on the reverse side hereof or attached hereto is correct and true to the best of my knowledge.
I understand that the permit must be obtained before any construction is begun.1 fisher state that I am D the owner of the property,n the owner's authorized*representative,a.a Licensed Well Drilling Contractor
Signed:_^/Date*
Jlhl^
-
PERMIT Fee received:0 fTobe completed by the Health Department
Permitto Begin Work Approved by Receipt No.:
Date Issued
Expires one year from date of issuanceAdditionalPermittoDestroyDryHoJePriortoSiteAbandonment
C
□
special ConationsIi
NOTE:1.Provide a minimum twenty-four (24)hour notice prior to installing or placing sanitary seal or drilling a well expected to be completed in less than
^twer^.y-four (24)hours.
2.A satisfactory inspection by the Health Department and receipt by the Health Department of a Driller's Report ora satisfactory abandonment report and a
disinfection statement is required for final approval of work.
>●●Copy 1-Applicant
Copy 2 -Health Department
b
iPZoneSReq.SB.
Pci.Status
PREPARE IN DUPLICATE.
r
*●t \●
(Within 200 feet of well site show}
(a)Property lines and existing and proposed buildings,(b)Sewage disposal systems,
sewer lines,and any other works carrying or containing sewage,(c)All intermittent
perennial,natural or artificial bodies of water or water courses,(d)Other wells,
(e)The approximate drainage pattern and areas subject to flooding.
i—f
i
T
3 T b l>*KiiilHP5'7T
k
:s i3:^3:!!«f
&ll/
I !.T^-
(
i:7
I,Vtmi /
+3
I 1
r
I VdVixf 2l s■;SCALE 1 in.60 f
NOTE:(1)To facilitate issuance of your well permit,please stake and flag the proposed well
location on the site.
(2}Review of this plot plan for well location does not imply that a sewage system will
be approved for any proposed construction.
1\
DWR use ONLY —00 NOT FILL INQUADRUPLICATE^or L6c'al hequirements
Eage
Owner’s Well No.
Date Work Began
Local Permit
t Permit No.
STATE OF CALIFORNIA
WELL COMPLETION REPORT 1iSTATEWELLNO./STATION NO.Refer to Irtsiruciiort Pamphletofn-n-92 u-13-Ba 414671
ft County Snv.Health Dept.,
*^*Permit Dale —
No i i iii
LONQITUOELATITUDE
Butt I I J Li1 J
APN/TBS/OTHER
5 WELL OWt^BandSandraTaylor
11975—Kvy ~7tr
Ca.
GEOLOGIC LOG RayXNameORIENTATION(:L)VERTICAL HORIZONTAL (SPECIFY)
(FL)BELOW SURFACE
ANGLE
DEPTH TO FIRST WATER 95965«TOEPTRFROMSURFACEDESCRIPTION STATECITY ZIPDescribematerial,f^ain size,color,etc.%to 11975 HV/^
urovlllftr
Butte
LOCATION9«ap aeona 7 ;clay and biuKeu lUuK
clay 30 1auCt ulay
soap fttone soft "Spot (qua«#«>aJd bluft re68«!grftsn and blue roe^c Latitude.
90 'soft (whits grssn and blue rccle
■virt (white jnren and blue IT c't
Address
City
County
APN Book
7-«■
«■U5«-ZOO Parcel.
Section
Longitude
Page .
Range-36-55-T5T77TIIR^or
5*
NORTH WESTi1iDEG.MIN.SEC.DEG.MIN.SEC.
-LOCATION SKETCH
NORTH —ACTIVITY {'L)—
NEW WELL
60-
90 ;110 MOOIFICATION/REPAIRNftdhardrocfsoftspot
bXus rock and quarts
soft sput
blue aud g;o«ri lucX.quarts
hard yissii and blur ruck—
110 '130
130 'HO
t40 ;157157~:165
165 i168
168 !240
Dsepen
Other (SpscilY)
J
DESTROY (DescribeProceduresendMaterfs/sUnder'G£OtOG/C LOG")
-PLANNED USE(S)-
MONITORING
H (A<n <w
WATER SUPPLY'J X.\Oomsslic
Public
\Irtigalloi
Industrialenvlrenirssnt&l Heallh "TEST WELL"
CATHODIC PROTEC-WfiR'16 1993 SOUTHIllustrateorDescribeDistanceof Well from LandmarkssuchosRoads,SuiWfnps,Fences,Riuers,etc.PLEASE BE ACCURATE i>COMPLE^TE.
TIONOTHER (Specify)
OroviliQ.California Pftrcussiot waterDRILLINGMETHOD.FLUID
E^EL &YIELD OF COMPLE’^EjD^^JLIgj
(Ft.)&DATE
(GPM)&TEST TYY2-g-_(Hrs.)TOTAL DRAWDOWN
*May not be representative of a 'well's long-term yield.
WATER L
DEPTH OF STATIC
WATER LEVEL T
ESTIMATED YIELZ4aTOTALDEPTHOFBORING
TOTAL DEPTH OF COMPLETED WELL
(Ft.)TEST LENGTH
{Feel}
CASINC(S)ANNULAR MATERIALDEPTH
FROM SURFACE DEPTH
FROM SURFACEBORE
HOLE TYPE (zi )TYPEINTERNAL
DIAMETER
(Inches)
GAUGE
OR WALL
THICKNESS
SLOT SIZE
IF ANY
(Inches)
D1A.MATERIAL/
GRADE
BEN-K CE-sSsu FILTER PACK(TYPE/SIZE)
z(Inches)a.TONITE FILLMENT
0^)Fl.to Ft.Ft.to Ft.l^){^)■r46t3 lispsi
Ix8x63i4aldftg
JJ 57 TtT X X
«■^4
551—05 -4-5
ATTACHMENTS (il)—CERTIFICATION STATEMENT
thg ^^iccurate to the best of my knowledge and beliefI.the u__Gedoeic Log
Well Construelion Diagram
Geophysical Log(s)
Soil/Waler Chemical Arulyses
Other
NAK1E (Pr.v:%OR CORP.OX Ca.95965
ADDRESS /CITY ,STAIE ZIP
SignedATTACHADDITIONALINFORMATION.IF IT EXISTS.WEU DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGHED C S?LICENSE NUMBER
IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORMDWB188REV,7-90
Environmental Health
SEP 2 2 1994
Oroville.California
Assessor's Parcel Number <0-5 t -<500 -ecu'
1469 Humboldt Road
Chico,CA
(916)
7 County Center Drive
Oroville,CA
(916)
95928
891-2727
95965
538-7281
BUTTE COUNTY ENVIRONMENTAL HEALTH
.Note;THE WELL DRILLER IS TO FILL OUT AND SIGN THEATTACHEDWELLDRILLER'S REPORT,ONE COPY OFWHICHMUSTBERETURNEDTOTHEENVIRONMENTALHEALTHDEPARTMENTAFTERTHEWELLISDRILLED.A STATEME_NT OF DISINFECTION IS ALSO TO BE
S.ENT TO THE ENVIRONMENTAL HEALTH DEPARTMENT
IN ORDER TO FINAL THE WELL PERMIT.ATTACHED SHEET FOR INSTRUCTIONS.SEE
f^/ok Puiper.sNameofpersonwhoperformed disinfection
/-Iluu 70
Address
The disinfection of the well was performed bydirectionat:me,or under myHuu-7D
Address or location
Using one pint of household chlorine bleach or 3 oz.ofchlorinatedlimeper100gallonsofwaterassetforth on theformS64-1066 entitled WELL DISINFECTION supplied by the ButteCountyvironmenatalHealthDepartment.
Tignature
Date