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Environmental Health Department <br /> SAN.]0A0UIN <br /> COU NTY, <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply 21ndustrial ❑ 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: ❑ Domestic iydrrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑ Other: <br /> Total Depth(ft. pv To: From: <br /> Casing Diameter(in): C) J"0 C ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pu irfg Rate(gpm): '(0 k.-) To: <br /> Annual Extr ' n Volume(acre-feet: Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> ATER' ABLE INEIRMAT QN` , <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: o <br /> Lowest Water Table: o <br /> Recharge Area: z_r? Recharge Rate: <br /> 51TING INFORMATION: <br /> Distance To Nearest(ft): Onsite. Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: f Transmission Lines: <br /> Onsite Well: Pond/Lake: C /`, ✓�i <br /> Sewer Lines: Stream/River: �/ i✓ <br /> Animal of Fowl Enclosure: r <br /> °MAP y )F `� �)v� wr " 7w r E 6'j .i INFORMATION , ° <br /> Amap 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 low Corcoran clay, map must show location of canals,ditches, pipelines, utility corridors, and roads within two miles. <br /> I hereby c i thatth infor "on I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date; h /Z�7-j/P <br /> Information Provide By: Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />