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x Environmental Health Department <br /> SAN: JOAOUIN <br /> ----COUNTY— <br /> Well <br /> ---COUNTY Well#2 Information- <br /> Use of Well: ❑Domestic ..Irrigation ❑ Small Public Wate+�Supply El Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): 70 r To: From: <br /> Casing Diameter(in): Iq <br /> 5(Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): fn ��� ,� ,� To: From: <br /> Annual Extraction Volume(acre-feet: (ci -`dEstimated 11Measured <br /> Specific Capacity,.(gal/min/ft): e4,1)-7 <br /> Other Pumping.Tests Performed: Voq z- Test Result: <br /> Well#3 Inform on <br /> Use of Well: ❑ Domestic 121"�Jrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑ Other: <br /> Total Depth(ft): L/O To: From: <br /> Casing Diameter(in): frn ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): O,00 i4/i To: From: <br /> Annual Extraction Volume(acre-feet: /Q 2rtstimated ❑ Measured <br /> Specific Capacity(gal/min/ft): # �✓h <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: L lr'-) �G>� t -cvtL 2 t <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: Offsite: <br /> Wastewater Treatment System: r,VVL 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 /> l hereby certify that the information/have provided is accurate and truthful to the extent reasonably known. <br /> Signed: ��- / /��- Date: 2 2— <br /> Information <br /> Information Provided By: 14ell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />