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SAN.JOAQUIN1 <br /> <br />Environmental Health Department <br />COUNTY <br />Well #2 Information <br />Use of Well: gDomestic 0 Irrigation 0 Small Public Water Supply 0 Municipal Public Water Supply 0 Industrial 0 Stock <br />0 Other: <br />Total Depth (ft): <br />0 Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): To: From: <br />Pumping Rate (gpm): To: From: <br />Annual Extraction Volume (acre-feet: 0 Estimated 0 Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: Test Result: <br />Well #3 Information <br />Use of Well: 0 Domestic 0 Irrigation 0 Small Public Water Supply 0 Municipal Public Water Supply 0 Industrial 0 Stock <br />0 Other: <br />Total Depth (ft): <br />0 Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): To: From: <br />Pumping Rate (gpm): To: From: <br />Annual Extraction Volume (acre-feet: 0 Estimated 0 Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: <br />Highest Water Table: <br />Lowest Water Table: <br />Recharge Area: Recharge Rate: _ <br />SITING INFORMATION <br />Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: <br />Wastewater Treatment System: Transmission Lines: <br />Onsite Well: Pond/Lake: <br />Sewer Lines: Stream/River: <br />Animal of Fowl Enclosure: <br />MAP INFORMATION <br />A map of the well location must be attached to this form and shall include the following information: <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 proposed well to any potential sources of pollution onsite and on adjacent properties, including; <br />0 Existing or proposed onsite sewage treatment systems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />0 Distance from ponds, lakes, and streams within 300 feet. <br />0 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: <br />Information Provided By: <br /> 111 Well Driller C7 Well/Property Owner 111 Other: <br />EHD 4300 12-21-2017 2 of 2