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SAN J 0 A Q U !N , (•� Environmental Health Department <br /> r. <br /> --COUNTY— <br /> Well <br /> —COUNTY Well#2 Information <br /> Use of Well: <br /> ❑Domestic Irrigation El Small Public WateF�S`�upply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): 755. To: From: <br /> Casing Diameter(in): lc/ 41 XOpen Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): , pD fn yn �rv � To: From: <br /> Annual Extraction Volume(acre feet: �i ---dEstimated 1:1 Measured <br /> Specific Capacity,(gal/min/ft): NdC,,,, ~' <br /> Other Pumping=Tests Performed: ,,-)0 y Test Result: <br /> Well#3 Informflon <br /> Use of Well: ❑Domestic 2"Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): fl'A ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): )1,00 1,,1 To: From: <br /> Annual Extraction Volume(acre-feet: lQ( Itstimated ❑ Measured <br /> Specific Capacity(gal1min/ft):1&V <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: U 0 j) L G i,,) --, -Ckl. <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION t _-ty,,6Z L&"q, <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: tU r iV�vv.�' Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <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 certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: �rL- /�/ -- Date: 2 r 2— <br /> Information <br /> Information Provided By: Q4ell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />