Laserfiche WebLink
SANJ 0 A Q U I N Environmental Health Department <br /> Well#2 Information <br /> Use of WTo <br /> omestic �Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial X Stock <br /> ther: <br /> Total Depth )T <br /> To: From: <br /> Casing Diameter(i— Ip i p Open Bottom or Screen Interval(ft): To: From <br /> Pumping Rate(gpm):l 400 ( m: <br /> i To: _ From: <br /> Annual Extraction Volume{acre feet j,&y-&- 1❑ Estimated ❑ Measured <br /> T <br /> Specific Capacity(galimin/ft): <br /> Other Pumping Tests Performed: —� - -- Test Result: <br /> IWell#3 Information <br /> r i Ll Domestic 13Irrigation O Small Public Water Supply ❑Municipal Public Water Supply [1 Industrial ElStock <br /> Use of Well:l <br /> i 1 U Other: <br /> Total Depth(ft):I To: From: <br /> --- - --- <br /> Casing Diameter(in): - ❑Open Bottom or Screen interval(ft): i To: _ From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gallminlft): <br /> Other Pumping Tests Performed: Test Result <br /> WATER TABLE INFORMATION - <br /> i Depth(ft): , Source of Reference: Date of Reference: <br /> Cu- - f--- -— - -- —__.. <br /> rrent Water Table-:- <br /> Highest Water Table: T-� - <br /> . tt . -war'. <br /> Lowest Water Table_ <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION_ 4 <br /> Distance To Nearest A. Onsite: Offsite: Distance To Nearest(ft): Onsite: offsite: <br /> - -- - _ <br /> Wastewater Treatment System, Transmission Lines: <br /> Mn i. _ ' <br /> ��--- __ _____.__.._ /20_ <br /> Pond/Lake: <br /> Sewer Lines: i j Stream/Mver: <br /> Animal of Fowl Enclosure: Nd/1 f I YLtl _ <br /> MAP 1NOORMATION - - - <br /> A_map of the well location must be attached to this_form and shall include_the following informafion-, _ <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 pro sed well to any potential sources of pollution onsite and on adjacen_properties, including: <br /> e Existin or proposed onsite sewage treatments sy tems,weils,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 /> I hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: 7-/G-20 <br /> S <br /> Information Provided By: ❑ Well Driller LR( Well/Property Owner ❑ Other <br /> r; 47,90 12-2-11JA 2 of 2 <br />