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SAN,IOAQUIN COUNTY Environmental Health Department Well #2 Information Distance To Nearest (ft). Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Pond/Lake: ❑ Other. Stream/River: Animal of Fowl Enclosure: Total Depth (ft): To: From: Casing Diameter (in): ❑ Open Bottom or Screen Interval (ft): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well #3 Information ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Use of Well: ❑ Other. Total Depth (ft): To: From: Casing Diameter (in): ❑ Open Bottom or Screen Interval (ft): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gallmin/ft): Other Pumping Tests Performed: Test Result: WATER_ AB IN ORM 't0[ Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: AA�� CCtt !T{ 'M/1F'It�l'I,000j . A map of the well location must be attached to this form and shall include the following information: • Le al 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 ad'acent properties, including: 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 hereby certify a e I o nation 1 have provided is accurate and truthful to the extent reasonably known. Signed: Date: W - 0 •ZOLL Information Provi By: 1 Well Driller ❑ Well/Property Owner ❑ Other: EHD 430012-21-2017 2 of 2 Distance To Nearest (ft). Onsite. Offsite: Distance To Nearest (ft): Onsite. Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: Sewer Lines: Stream/River: Animal of Fowl Enclosure: AA�� CCtt !T{ 'M/1F'It�l'I,000j . A map of the well location must be attached to this form and shall include the following information: • Le al 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 ad'acent properties, including: 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 hereby certify a e I o nation 1 have provided is accurate and truthful to the extent reasonably known. Signed: Date: W - 0 •ZOLL Information Provi By: 1 Well Driller ❑ Well/Property Owner ❑ Other: EHD 430012-21-2017 2 of 2