Laserfiche WebLink
)A N J O A Q f I N Environmental Health Department <br /> CC>IJIJTY <br /> Well#2 Information <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> , Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Scree5 INerval(fl): To: From. _ — <br /> Pumping Rate(gpm): To: From <br /> Annual Extraction Volume(acre-feet: -E] Estimated ❑ Measured <br /> Specific Capacity(gal/min/fl): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: E-1Don �c 17-1Irrigation ❑Small Public Water Supply EI Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(fl): To: From. <br /> Casing Diameter(in): ❑0 n'8ottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gallminlf <br /> Other Pumping Tests P rmed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <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: tollqi UVIY WV) Transmission Lines: npya u0nown <br /> Onsite Well: none V&r 1p0o' Pond/Lake: ntDy'le, nvnowy) <br /> Sewer Lines: nOYle/ Over (jQ)r Stream/River: hom U kyj%y4V) <br /> Animal of Fowl Enclosure: yxo"Q1 UnWVVIh <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 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: jb6y ► V k�aas r <br /> Information Prov ed By: Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHE 4300 12-21-2017 2 or 2 <br />