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SAN. 1 O A Q U I N Environmental Health Department <br /> ---COUNTY - - <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply 0lridustrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): To: From: <br /> '—_Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping-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 /> Well#3 Information <br /> Use of Well: <br /> El Domestic olrrigation ❑Small Public Water Supply EJMunicipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft). pb— To: From: <br /> Casing Diameter(in): C)" �UC. ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pum' ing Rate(gpm): To: om: <br /> Annual Extract' n Volume(acre-feet: Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft)- <br /> -'Other Pumping Tests Performed: Test Result: <br /> CATER . r: <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: I.0 <br /> Highest Water Table: o <br /> Lowest Water Table: l 020 <br /> Recharge Area: t Recharge Rate: 3 �l <br /> j <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: a Transmission Lines: <br /> Onsite Well: Pond/Lake: f /� f✓ -3 <br /> Sewer Lines: Stream/River: //,/,} <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <br /> A ma 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 low Corcoran clay, ma must show location of canals,ditches, pipelines, utilitycorridors, and roads within two miles. <br /> I hereby c i that th infor 'on_I have provided is accurate and truthful to the extent reasona ly known. <br /> Signed: Date: <br /> Information Provide By: Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />