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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Well#2 Information <br /> Use Well: omestic ❑ Irrigation El Small Public Water Supply El Municipal Public W r Supply El Industrial El Stock <br /> ❑ Other: <br /> tal Depth(ft): o: From: <br /> Casing Dia er(in): << ❑ Open Bottom or Screen Inte (ft): To: From: <br /> Pumping Rate(aN. i To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estima ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation mall Public Water Su ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth To: From: <br /> Casing Dia er(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> P g Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ 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 /> Highest Water Table: <br /> Lowest Water Table: C� <br /> Recharge Area: a Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: Sb-- <br /> Onsite Well: Pond/Lake: 0 <br /> Sewer Lines: 4" Stream/River: 0 . <br /> Animal of Fowl Enclosure: NUYLQ,. <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 /> 1 hereby c i that the info tion ave proved is accurate and truthful to the extent re a onably known. <br /> Signed: �r.� Date: / 1 , <br /> Information Provided El Well Driller ElWeIllProperty Owner Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />