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SANAOAQUIN <br />COUNTY <br />Environmental Health Department <br />Well #2 Information <br />Distance To Nearest (ft). <br />Use of Well: <br />❑ Domestic ❑ Irrigation <br />❑ Other. <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply <br />❑ Industrial ❑ Stock <br />Total Depth (ft): <br />Highest Water Table: <br />To: <br />❑ Open Bottom or Screen Interval (ft): To: <br />To: <br />From: <br />From: <br />From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet: <br />Recharge Area: <br />❑ Estimated ❑ Measured <br />Recharge Rate: <br />Specific Capacity (gaVmin/ft): <br />Other Pumping Tests Performed:1 <br />Test Result: <br />Well #3 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation <br />❑ Other. <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply <br />❑ Industrial ❑ Stock <br />Total Depth (ft): <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />To: <br />❑ Open Bottom or Screen Interval (ft): To: <br />To: <br />From: <br />From: <br />From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: <br />Test Result: <br />WATER3 EdfWATtOi <br />Distance To Nearest (ft). <br />Depth (ft): Source of Reference: <br />Date of Reference: <br />Current Water Table: <br />Onsite Well: <br />Pond/Lake: <br />Highest Water Table: <br />Stream/River. <br />Animal of Fowl Enclosure: <br />Lowest Water Table: <br />Recharge Area: <br />Recharge Rate: <br />'rye�(( (( <br />�`j': .� ...: ?tF"^'°`L"� - . :t;T T"',i.e•. a ::.. , . .. <br />Distance To Nearest (ft). <br />Onsite. Offsite: Distance To Nearest (ft). Onsite. Offsite: <br />Wastewater Treatment System: <br />Transmission Lines: <br />Onsite Well: <br />Pond/Lake: <br />Sewer Lines: <br />Stream/River. <br />Animal of Fowl Enclosure: <br />��; °i!l'�V'T �rr" i«Yf-aw .i'-`vT-.`�.. +ti S{J.. �i.}.+T •'N.i'.4,.:S .rah•T�' ...f711.� <br />v.'. �?�57.,r 1.•.,..�` <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 />• Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br />o <br />EAsting 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, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />/hereby ce at the i formation I have provided is accurate and truthful to the extent reasonably known. <br />Signed: Date: <br />Information(rovid By: ell Driller ❑ Well/Property Owner ❑Other. <br />EHD 4300 12-21-2017 2 of 2 <br />