HomeMy WebLinkAbout056-410-020 EHWS24-0057 WELL DISNFCTN STMNTDisinfection Instructions: A Chlorine solution is used for well disinfection. Contact the County
Environmental Health Division if there are any questions.
Section 23B-9 of the Code of Butte County requires a completed Statement of Disinfection to be on file
in order for a water well installation to be finaled by this Department.
STATEMENT OF DISINFECTION
Assessor Parcel NumberG/a��
Name of Property Owner ` nfAMgc?)n deule_��
Address/Location of drilled well
Name of person who performed disinfection A rlr, c, c cr
Mailing Address 19(� H r.r_ a„ L.„ t 'cC N 9 r` P Phone # fp)
Signature of person performing disinfectionri
Date of disinfection 1-,4Q- 2 p.Z5
Please return this Statement of Disinfection to: Butte County Environmental Health Division
202 Mira Loma Drive
Oroville, CA 95965
CtericdIFORMS/Disinfectim Stzt m l