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SKJOAQUIN — -COUNTY— - Environmental Health Department Well #2 Infomiation 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 Specific Capacity (gallmin/ft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other. Total Depth (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gafmirdft): Other Pumping Tests Performed: Test Result: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: Redida Rate: MAP INF~TIaN 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 kxations 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, including: o Existing or proposed onsite sewage treatrnent systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, takes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pi ines, utility corridors, and roads within two miles. I hereby certify information provided is accurate and truthful to the extent reasonably Down. Signed: Date: Information Provi Br _,VWell griller ❑ Welliftperty Owner ❑ Other: EHD 4300 12-21-2017 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: MAP INF~TIaN 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 kxations 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, including: o Existing or proposed onsite sewage treatrnent systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, takes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pi ines, utility corridors, and roads within two miles. I hereby certify information provided is accurate and truthful to the extent reasonably Down. Signed: Date: Information Provi Br _,VWell griller ❑ Welliftperty Owner ❑ Other: EHD 4300 12-21-2017 2 of 2