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Jul, 31. 2018 8: 05AM Canepa & Sons No. 2347 P. 5
<br /> ANti,,J Q U N Environmental Health bepartment
<br /> Q t,.1 N..t.Y_._.,.... i
<br /> Well#2 Information
<br /> Use of Well: ❑ 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(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: a 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(gpm): To: From:
<br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured
<br /> Specific Capacity(gal/min/ft):
<br /> Other Pumping Tests Performed:1 Test Result:
<br /> W T li, IJ i 1(J�!i 111 YJ1, i d ii"'k it i Sl>}!4!_ 1 i 1'�i frt d s
<br /> A ERTAB ,,E,INFORMATI�N,,,z11;!,11.4 13,,EaM1t,n ;„!,x,I�Jitr;lY,i
<br /> Depth (ft): Source of Reference: Dake of Reference:
<br /> Current Water Table: 0' (,/NF✓` p�� pTU tlNp 87121997
<br /> Highest Water Table:
<br /> Lowest Water Table:
<br /> Recharge Area: Recharge Rate:
<br /> SITING). ... ., . ..... -.... . . ... ... .. ,,1:,„6,
<br /> �t
<br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: offsite;
<br /> Wastewater Treatment System: MIA (app+ Transmission Lines: fA I A ) -f-
<br /> Onsite Well: Pond/Lake: NIAI owfi
<br /> Sewer Lines: OpO+ Stream/River: N
<br /> Animal of Fowl Enclosure: N I A 10007t
<br /> 1'h'' ' ;,1�..1'1�� !.<<�. .' ' J .�r;ct;i rkiil!il'l�'I°�i iu_,.�,!��:_:::a::..:::•:�t:::.:•: :_:” i � �,
<br /> MAP.INFORMATi14N,;;,,:,., ;,L;i . .. .. ............ i . I!....+ I. ,c,�trh,rlt At;•<< ;, _:-:-=
<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 properlies, 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 wilhin 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 ce J that the i rmation I have provided is accurate and truthful to the extent reasonably known.
<br /> Signed; Date- 1�
<br /> Information Provided B , Well D er El Well/Property Owner ❑ Other:
<br /> EHD 4300 12-21-2017 2 of 2
<br /> Received Time Ju1, 31. 2018 8 : 24AM No- 3944
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