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SAN JOAQUIN —COU NTY— Environmental Health Department Well #2 Information NA 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: ❑ Estimated ❑ Measured Onsite Well: Specific Capacity (gal/min/ft): Other Pumping Tests Performed: I Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): O F ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): 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: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: 153 / — Al —.2 a Highest Water Table: ( S Muz;�uk (�, 17707 2- —3—Q( Lowest Water Table: C,N Recharge Area: Recharge Rate: Transmission Lines: SITING INFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: C,N �� Transmission Lines: Onsite Well: I 2—c> JPond/Lake: Sewer Lines: o bVea a. - Stream/River: Animal of Fowl Enclosure: 0a, 4Axr, O F 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 propeqies, 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, nl4must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. 1 hereby certify that the ihforr �*bn 1 have provided is accurate and truthful to the extent reasonably known. Information Provided By: Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2