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SAN JOAQUIN -- COUNTY-- - Environmental Health Department Well #2 Information Use of Weli. jornestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply 121ndustrial 11Stock ❑ Other: Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): /00 To: From: Annual Extraction Volume (acre-feet: /AcA ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Z),UKJ-19Lj Other Pumping Tests Performed: j6W1e1JeZ,.W Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: El ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed:1 I Test Result: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: 0 Lowest Water Table: /0 Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: 00 Transmission Lines: Onsite Well: / (7 Pond/Lake: Sewer Lines: Stream/River:'j�) 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 p9pds, lakes, and streams within 300 feet. o For wells beloA jorcoran clay, ma must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby Signed: Information Provided By: have provided is accurate and truthful to the extent reasonably known. ,".", {" Date: 7 '3-l) _,� / ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2