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SA N J 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 ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total De th ft: To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed:1 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): To: From: <br /> Casing Diameter(in : ❑ Open Bottom or Screen Interval (ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/minlft <br /> Other Pumping Tests Performed:1 Test Result: <br /> WATER TABLE INFORMATION <br /> Depth (ft: Source of Reference: Date of Reference: <br /> Current Water Table: C10 ,*-A r 7- <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Rechar e Rate: <br /> SITING INFORMATION <br /> Distance To Nearest ft : Onsite; Offsite: Distance To Nearest(ft): Onsite Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: ' Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and-shalt 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 /> EHD 4300 12-21-2017 2 of 2 <br />