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SANJ O A Q U I N Environmental Health Department <br /> COUNTY - <br /> Well#2 Information <br /> Useell: omestic 11Irrigation ❑ Small Public Water Supply ElMunicipal Public W r Supply ElIndustrial ElStock <br /> Gt _❑ Other: <br /> tal Depth(ft): o: From: <br /> Casing Dia er(in): �` ❑ Open Bottom or Screen Inte (ft): To: From: <br /> Pumping Rate(g j To: From: <br /> Annual Extraction Volume(acre-feet: ic <br /> ❑ 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 El Industrial ❑ Stock <br /> El Other: <br /> Total Depth_W. 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: 100 <br /> Highest Water Table: I I P <br /> Lowest Water Table: CA, <br /> Recharge Area: L: � e Recharge Rate: l1�DyV? <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: 7 t Transmission Lines: Z 4- <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: -4" Stream/River: <br /> Animal of Fowl Enclosure: �/OYLQ, <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 tl�e info tion ave provi#ed is accurate and truthful to the extent rea ona4ly known. <br /> i ' <br /> Signed: ,� 1 Date: -)-n I e <br /> Information Provided ❑ Well Driller ❑ Well/Property Owner Other: Mw,l ,, <br /> EHD 4300 12-21-2017 2 of 2 <br />