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09/14/2018 07:58 Canepa a Sons (FAX) P.005/010 <br /> SANp n (j 1 I N I Environmental Health Department <br /> COUNTY <br /> Well 02 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply n 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(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated O Measured <br /> Specific Capacity(gal/min/ft). <br /> Other Pumping Tests Performed: Test Result:; <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial O 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 O 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: r qq-7 <br /> K <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offslte: <br /> Wastewater Treatment System: AtIA Transmission Lines: N H N A <br /> Onsite Well: Pond/Lake: N N <br /> Sewer Lines: h44 Stream/River: k <br /> Animal of Fowl Enclosure: N k <br /> A I <br /> If <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 pollutlon 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 /> I hereby cert' of the i rmat' /have provided Is accurate and truthful to the extent reasonably known, <br /> Signed: Date: n9 jb <br /> Information Provided y: Well riller ❑ Well/PropertyOwner El Other: <br /> E'Received Time Sep, 14, 2018 7 : 52AM No, 4131 <br />