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SANJ O A Q U I N Environmental Health Department —COUNTY— EXISTING WELLS INFORMATION Total Number Exls6n Wells on Pro a Please complete the IMormaflon below forevery well on m 1191 Information property. Use of Well; 0 Dome site 11Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial []StockL9�Other. }Doc t N ll,SIC—_ Total De th ft: d� To: From: Casioo Diameter n: Screen Interval(ft): To: From: Pumping Rate m: To: From: Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured S cific Ca ad allmin/ft: Other Pumping Tests Performed: ITest Result Well>#2Information Use of Well: CiDomestic ❑ Irrigation Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total De th ft: To: From: Casing Diameter n: Screen Interval(ft): To: From: Pum in Rate m: jSb To: From: Annual Extaolion Volume(acre-feet 5 arc �u� b�Estimated ❑ Measured S ecific Ca act al/min/ft Other Pum in Tests Performed; Test Result Well#f3 Information Use of Well: 0 Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑ Stock ❑Other. Total Depth ft: To: From: Casing Diameter in: Screen Interval(ft): To: From: Pumping Rate m: To: From: Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured Specific Capacity allmtn/ft: Other Pumping Tests Performed: Test Result MAP INFORMATION A project site map must be attached to this form and shall include the following information: • Legal lot and parceldimensions. • All well locations on legal lot and parcel with type and use Information shown for each well. • All onsite sewage treatments stems stormwater ponds,process water ponds,and other sources of potential contamination. • Distance from proposed well to any potential sources of pollution onsite and on ad scent properties,including: o Existn2 or proposed onsite sewage treatments stems,wells animal or fowl enclosures transmission lines sewer lines. o Distance from ponds,lakes,rivers and streams within 300 feet and navigable water was wrlmn one mile. o For wells below Corcoran c1gy map must show location of canals ditches pipelines,utifty corridors and roads within two miles. 2of2