WP0043572 - Laserfiche WebLink

Home Browse Search

SAN 10AQUIN —r JNTY Environmental Health Department Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other. ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): Wastewater Treatment System: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): Annual Extraction Volume (acre-feet: 1.I %q ❑ Estimated ❑ Measured N til Specific Capacity (gallmirdft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic El Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): Casing Diameter (in): Pumping Rate (gpm): To: ❑ Open Bottom or Screen Interval (ft): To: To: From: From. From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gallminlft): Other Pumping Tests Performed: Test Result: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: f a o �`� F �i r. L o Q_ l'a- Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest (ft): _ Onsite: T Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: r -j Sewer Lines: Stream/River: 1.I %q Animal of Fowl Enclosure: N til b -- MAP INFORMATION A map of the well location must be attached to this form and shall include the followinginformation: -- -- • 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 properties, including: 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, map must show location of canals ditches, pipelines, utility corridors, and roads within two miles. /hereby certify tpl a�the info ation I have provided is accurate and truthful to the extent reasonably known. Signed: - - - - - Date: Information Provided By: Well Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017