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SAN.ftAt' I O AQ <br /> i I �I Environmental Health Department <br /> C r-fJLl hJ T Y I c y <br /> ' •: :, EXIS`PINGW�t:�S.tMF.ORMATION, _ . � • <br /> Total Number Existing Wells on Pro e . 02- Please cam to the Inkumsfi'on be;ow for every welf an property.Use extra paper if needed <br /> Well lll(Inforrriation.: <br /> Use of Well: 'Domestic O Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply O Industrial G Stool, <br /> ❑ Other. <br /> Total Deoth'ft: To: From: <br /> Casing Diameter in : Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(ace-feet: ❑ Estimated L Measures <br /> Specific Capacity ' aliminrft <br /> Other Pumping Tests Performed: _ Test Result: <br /> Well#2:fnfb"' tiori; - - <br /> Use of Well: ❑ Domestic :3Irriga ion 11 Small Public Water Supply ❑Municipal Public Water Sunal;� C Industrial O Stock <br /> Use ofWaill <br /> Other. 0 N�f 44 T=-64 <br /> Total Depth f': To: From: <br /> Casino Diameter(in): Screen Interval(ft): To: From: <br /> PumDinc Rate pm : ! To: From: <br /> Annual Extraction Volume(acre-feel: ❑ Estimated ❑ tAeasured! <br /> Specific Capacity alhnin,4t : <br /> Other Pumping Tests Performed'I I Test Result: <br /> 'Well#3�InfoFi4tation _ .� ,. <br /> Use of Well: <br /> D Domestic 0 Irrigation ❑Small Public Water Supply o Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft),. To: From: <br /> Casing Diameter in : Screen Interval(ft): To: From: <br /> Pumoin Rate( pm): To: From: <br /> Annual Extraction Volume(acre-feet: 0 Estimated ❑ Measured <br /> Specific Capacity( alimin!fl <br /> Other Pumping Tests Performed: Test Result:: <br /> MAP IMRMABON <br /> A pTlect site map must be attached to this form and shall Include the b1lowing information: <br /> • Legal lot and parcel dimensions, <br /> • All well locations on legal lot and parcel with type and use infomiation shmn for each well. <br /> • All onsite sewage treatment systems,stormwater ponds, process water ponds,and other sources of potental contamination. <br /> • Distance from proposed.well to any potential sources of pollition onsite and on ad} cent properties, including: <br /> o Existing or proposed onsite se"Vage treatment,systems,wells, animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from ponds,lakes, rivers and streams within 300 feet and navigable water ways within one mile. <br /> o For wells below Corcoran clay, map must show location of canals,ditches,pipelines, utility corridors,and roads within hvo miles. <br /> 2of2 <br />