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SANJ O A Q U I N Environmental Health Department �. Well#2 Information Use of Well: ❑Domestic Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock ❑Other: Total Depth(ft): I To: From: Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Performed: Test Result: Well#3 Information Use of Well: ❑Domestic `p Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth(ft): To: From: Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): _ To: From: Annual Extraction Volume(acre feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Performed:1 Test Result: WATER TABLE INFORMATION Depth(ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: Wastewater Treatment System:' L"�/u Transmission Lines: w 350' Onsite Well: 1200' 300' Pond/Lake: /A N/A Sewer Lines: N/A 300' Stream/River. N/A N/A Animal of Fowl Enclosure: MAP INFORMATION A map of the well location must be attached to this form and shall include the following information: • Legal lot and parcel dimensions. • All well locations on legal lot and parcel with type and use information shown for each well. • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties,including: o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. o Distance from ponds, lakes,and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals,ditches,pipelines, utility corridors,and roads within two miles. I hereby certify tha the information I have provided is accurate and truthful to the extent reasonably known. Signed: Date: 9/11/20 Information Provided By: ❑ Well Driller ® Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2