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S A N�!OA Q U I N Environmental H¢alth Department <br /> —GOU NTY— <br /> -r ,, _ .,,, .. ... . .:...�EXi$'rlAlNG;W�};(..S iNF._Rdl YYQNi... ,_.. .. � ... .. _ .:. _. '. <br /> Total Number Existin Wells on Pro e O Please complete Ne InformeG'on(»bw rrn every well on property.Use exae paperHnaeded. <br /> We 11 `rrtiatiSM ..',R. _:'.. ::Yr Y.S.f. ':M1: � +..:y:.:' ,'o'..i. . . <br /> Use of Well: �,Domesfic O Imgadon o Small Public Water Supply D Munidpal Publlc Wafer Supply D Industrial �Stock <br /> 0 ofnar: <br /> Total De th ft: To: From: <br /> Casin Diameter In : Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated � Measuretl <br /> S ecific Ca a aUminRi <br /> Other Pum in Tests Pertormetl: Test Result: <br /> 'Wen ill n on-.- :::�._r ._ .. .. __ .F-_. .., .,,. <br /> Use of Well'_ �Domesfic o brig ion D Small Publlc Water Supply o Municipal Publie Water Supply D Intlustdal D Stock s <br /> �Other: ON }1KQ - <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): Tc: From: <br /> Pum in Rate m : To: From: <br /> Annual F_xtrection Volume(acre-feet: O Esdmefetl D Measuretl <br /> S etlfic Ca ad al/min/ft <br /> Other Pum in Tests Pertonnetl: Test Result: <br /> `Well'7/9'9,.. .., . lona. ._...: .... _ .. <br /> Use of Well: m Domestic o Irrigation O Small Public Water Supply o Municipal Public Wa[er Supply o Intlustrial O Siock <br /> O Ofher. <br /> Total De th R: To: From: <br /> Casin Diametar In : Sereen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet � O Eat{matetl � Measured � <br /> S ecific Ca d Vmin/ft <br /> Other Pum n Tests Pertortnetl: Tes[Result: <br /> .,.. .. .. - _MA71 RMATION .. - ..- ,-s '. <br /> A ro act site ma must be attached to this form and shall inclutle the followin information: <br /> L al lot and steel dimensions. <br /> All well locations on le al lot and reel with and use information shown for each well. <br /> All onsite sews a treatment s tams stormwater ontls rocess water nds,and other sources of otenRal contamination. <br /> Distance from ro Deed well to an tential sources of ollution onsite and on ad'acent o erties,inGudin <br /> o Eldstin or ro Deed onsite sews a treatment s tams,wells,animal or fowl enclosures transmission Tines sewer Tines. <br /> o Distance from onds,lakes rivers and streams within 30D feet and nevi able water wa s within one mile. <br /> o For wells below Corcoran cis ma must show location of canals ditches i alines,utili corridors and roads wimin two miles. <br /> z ota <br />