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SAN JOAQUIN -- — - O tJ i"J T; - Environmental Health Department EXISTING WELLS INFORMATION Total Number Existing Wells on Prope Please complete the information below for eveiy well on property. Use extra paper if needed, Well #1 Information Use of Well: D esti Jrrigation ❑ 0 eer:: ElSmall Public Water Supply El Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth ft : Casing Diameter (in): 16- Screen Interval (ft): may.. To: From: To: Fro Pumping Rate gpm : To: om: Annual Extraction Volume (acre-feet: ❑ Estimated O ured Specific Capacity al/min/ft : Test Result: Well #3 Information Other Pumping Tests Performe I 3Kt Result: ❑ Domestic ❑ Irrigation El Other: wen *2 information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Pu i r Supply r 42 ❑ Industrial ❑ Stock Total Depth (ft): To: Green Interval (ft): To: To: From: From: From: Casing- Diameter in : Pumping Rate gpm : 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 ❑ Irrigation El Other: is Water Supply ❑ Small Public Water Supply ❑10t El Industrial ❑ Stock Total Depth (ft): Casing Diameter (in): Pumping -Rate m : To: Screen Interval (ft): To: To: From: From: I From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed: Test Result: MAP INFORMATION A project site map 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. • All onsite sewage treatment systems, stormwater ponds, process waterponds, 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, weds, 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