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S A N JOAQUIN Environmental Health Department _.--—C 0U " TY__ - EXISTING WELLS INFORMATION Total Number Existing Wells on Property:l Please complete the information below forevery well on property. Use extra paper if needed, Well#1 Information Use of Well: Desti YJrrigation El Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock er,� Total Depth ft: To: From: Casing Diameter(in): Screen Interval(ft): To: Fro Pumping Rate g m: �,r•. To: om: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Uwured Specific Capacity al/min/ft Other Pumping Tests Performed- I Xt Result: Well 92nformation Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Pu i r Supply ❑ Industrial ❑ Stock ❑Other Total De th ft: To: From: Casing-Diameter in : creen Interval(ft): To: From: Pumping Rate pm : L 1v To: From: Annual Extraction Volume(acre-feet: V ❑ Estimated ❑ Measured Specific Capacity gal/min/ft;Other Pumping Tests Performed: Test Result: Well#3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑xr� is Water Supply ❑ Industrial ❑Stock ❑ Other: Total Depth ft: To: From: Casing Diameter(in): Screen Interval(ft): To: From: Pum in _Ratem : To: From: Annual Extraction Volume(acre-feet: 1VV ❑ Estimated ❑ Measure S ecific Capacity al/min/ft: Other Pumping Tests Performed:1 Test Result: MAP INFORMATION A project site map must be attached to this form and shall include the following information: • Legal lot andparcel arcel dimensions, • All well locations on legal lot and parcel with type and use information shown for each well. • All onsite sewage treatment systems,stormwater ponds,process water onds,and other sources of potential contamination. • istance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: Existing or proposed onsite sewage treatments stems,wens,animal or fowl enclosures,transmission lines, sew r lines. o Distance from ponds,lakes, rivers and streams within 300 feet and navigable water was within one mile. o For wells below Corcoran clay, map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. 2 of 2