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SANJOAQUIN <br />COUNTY <br />Environmental Health Department <br />Well #2 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />•2o ` oirlld afsx e. <br />❑ Open Bottom or Screen Interval (ft): <br />To: <br />From: <br />Casing Diameter (in): <br />Recharge Area: <br />To: <br />From: <br />Pumping Rate (gpm): <br />NOWT <br />To: <br />From: <br />Annual Extraction Volume (acre-feet: <br />lucue- <br />❑ Estimated ❑ Measured <br />Make-, <br />b 6eS 10 <br />Specific Capacity (gal/min/ft): <br />t100e, <br />NOMG, <br />Sewer Lines: <br />Other Pumping Tests Performed: <br />?ubh�, <br />Test Result: <br />Well #3 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />To: From: <br />❑ Open Bottom or Screen Interval (ft): To: From: <br />To: From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: <br />•2o ` oirlld afsx e. <br />Highest Water Table: <br />_ Zp <br />Lowest Water Table: <br />Offsite: <br />Recharge Area: <br />Recharge Rate: <br />SITING INFORMATION <br />Distance To Nearest (ft): <br />Onsite: <br />Offsite: <br />Distance To Nearest (ft): <br />Onsite: <br />Offsite: <br />Wastewater Treatment System: <br />NOWT <br />ubli, <br />Transmission Lines: <br />UawL <br />lucue- <br />Onsite Well: <br />Make-, <br />b 6eS 10 <br />Pond/Lake: <br />t100e, <br />NOMG, <br />Sewer Lines: <br />NoNL <br />?ubh�, <br />Stream/River: <br />ovAjL <br />Poo— <br />Animal of Fowl Enclosure: <br />V00L <br />NoNL• <br />MAP INFORMATION <br />A map of the well location must be attached to this form and shall include the following information: <br />• Legal lot and parcel dimensions. <br />• All well locations on legal lot and parcel with type and use information shown for each well. <br />• Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including. <br />o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />o Distance from ponds, lakes, and streams within 300 feet. <br />o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />I hereby certify that the information I have pr vided i ate and truthful to the extent reasonably known. <br />Signed: � Date: <br />Information Provided By: Well Duller Well/Property Owner ❑ Other: <br />EHD 4300 12-21-2017 2 of 2 <br />