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SAN JOAQUIN ---COU N T Y --- Well #2 Information Use of Well: ❑ Domestic ® Irrigation ❑ Other: Total Depth (ft): Casing Diameter (in): 1� Pumping Rate (gpm): s D Annual Extraction Volume (acre-feet: 3 Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other: Total Depth (ft): Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Environmental Health Department ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock To: From: Open Bottom or Screen Interval (ft): To: From: D To: From: 5 , Estimated ❑ Measured AVO A/fr Test Result: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock To: ❑ Open Bottom or Screen Interval (ft): To: To: ❑ Estimated ❑ WATER TABLE INFORMATION Depth (ft): Source of Reference: Current Water Table: 1,73 X Highest Water Table: I rp O Lowest Water Table: t ,(7 a Recharge Area: Recharge Rate: Test From: From.- From: rom:From: Date of Reference: SITING INFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Af F_ Transmission Lines: Onsite Well: y 43 ' Pond/Lake: Sewer Lines: t A�6n NapE Stream/River: 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, includin : o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. 1 nereivy cerriry mat me rntormation I have provided is accurate and truthful to the extent reasonably known. Signed: .,. `, Date: /0 -2�21 Information Provided By: Well Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 o;