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SAN JOAQUIN <br />COUNTY - <br />Environmental Health Department <br />Well #2 Information <br />Useell: <br />Gt_❑ <br />omestic 11Irrigation ❑ Small Public Water Supply ElMunicipal Public W r Supply ElIndustrial ElStock <br />Other: <br />tal Depth (ft): <br />Casing Dia er (in): �` ❑ Open Bottom or Screen Inte (ft): <br />Pumping Rate (g i <br />o: From: <br />To: From: <br />To: From: <br />Annual Extraction Volume (acre-feet: ❑ Estima ❑ Measured <br />CA, <br />Specific Capacity (gal/min/ft): ic <br />e Recharge Rate:�.�y�y� <br />Other Pumping Tests Performed: <br />Test Result: <br />Well #3 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation mall Public Water Su ❑Municipal Public Water Supply El Industrial ❑ Stock <br />El Other: <br />Total Depth_W. <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Dia er (in): <br />To: From: <br />P g Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: <br />Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: <br />100 <br />Highest Water Table: <br />I I P <br />Lowest Water Table: <br />CA, <br />Recharge Area: <br />e Recharge Rate:�.�y�y� <br />SITING INFORMATION <br />Distance To Nearest (ft): Onsite: Offsite: <br />Distance To Nearest (ft): <br />Onsite: Offsite: <br />Wastewater Treatment System: 7 t <br />Transmission Lines: <br />Z 4 - <br />Onsite Well: <br />Pond/Lake: <br />Sewer Lines: -4" <br />Stream/River: <br />Animal of Fowl Enclosure: <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 />/hereby c i that tl�e info tion ave provi#ed is accurate and truthful to the extent rea ona4ly known. <br />I '-)-n I e <br />Signed: ,� 1 Date:P)l <br />Information Provided ❑ Well Driller ❑ Well/Property Owner Other: Mw,l ,, V <br />EHD 4300 12-21-2017 2 of 2 <br />