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SANJOAQUIN ---COU NTY— Environmental Health Department Well #2 Infonnation Use of Well: ❑ Domestic Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): 1 ' ❑ 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 Gapacity (gaVmintft): a: Other Pumping Tests Performed: Test Result: Well 83 Inbnnation 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 (gal/mirvft): Other Pumping Tests Perbrmed:1 Test Result: _ - _ - A map of the well location must be attached to this form and shall include the folk)wing information: • Legal lot and parcel dimensions. • All well kxations on kial lot and parcel with My and use information shown for each well. • Distance from Wposed well tD any poenlJal sources of polkiton onsite and on adjacent ppperfies, including: o Existing or Koposed onsite sewage treatrnent systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, and sbewns within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby t i anon I have provided is accu and truthful to the extent reasonably known. Signed: Date: V �' •?i7i - Information Provided By: Well Driller ❑ WelUProperty Owner ❑ Other EHD 4300 12-21-2017 2 of 2 `+wx- DepM (ft): Source of Reference: Date of Reference: Current Water Table: Transmission Lines: Highest Water Table: Pond/Lake: Table: �R�echarge Stream/River. a: Recharge Rabe: _ - _ - A map of the well location must be attached to this form and shall include the folk)wing information: • Legal lot and parcel dimensions. • All well kxations on kial lot and parcel with My and use information shown for each well. • Distance from Wposed well tD any poenlJal sources of polkiton onsite and on adjacent ppperfies, including: o Existing or Koposed onsite sewage treatrnent systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, and sbewns within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby t i anon I have provided is accu and truthful to the extent reasonably known. Signed: Date: V �' •?i7i - Information Provided By: Well Driller ❑ WelUProperty 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 Livres: Stream/River. Animal of Fowl Enclosure: _ - _ - A map of the well location must be attached to this form and shall include the folk)wing information: • Legal lot and parcel dimensions. • All well kxations on kial lot and parcel with My and use information shown for each well. • Distance from Wposed well tD any poenlJal sources of polkiton onsite and on adjacent ppperfies, including: o Existing or Koposed onsite sewage treatrnent systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, and sbewns within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby t i anon I have provided is accu and truthful to the extent reasonably known. Signed: Date: V �' •?i7i - Information Provided By: Well Driller ❑ WelUProperty Owner ❑ Other EHD 4300 12-21-2017 2 of 2