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Environmental Health Department <br />SANsJOAQUIN <br />—COUNTY— <br />WATER TABLE INFORMATION <br />Depth (ft): I Source of Reference: <br />Current Water Table: <br />Highest Water Table: <br />Lowest Water Table: <br />Recharae Area: <br />Date of Reference: <br />SITING INFORMATIO.W` <br />Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: <br />Wastewater Treatment System: Transmission Lines: <br />Onsite Well: PondlLake: <br />Sewer Lines: Stream/River: <br />Animal of Fowl Enclosure: <br />MARINFORMAT10N <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 />urces of pollution onsite and on adjacent properties, including: <br />Distance from proposed well to any potential so <br />o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />o Distance from ponds, lakes, and streams within 300 feet. <br />o For wells below Corcoran clay, ma must show location of canals, ditches, pipelines, utili corridors, and roads within two miles. <br />1 hereby certi that the o o have provided is accurate and truthful to the extent reasonably known. <br />Date: " v <br />Signed: <br />Information v' ed By: Well Driller ❑ WelllProperty Owner ❑Other: <br />EHD 4300 12-21-2017 <br />2of2 <br />