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SAN JOAQUIN <br /> Environmental Health Department <br /> COUNTY <br /> Well#2 Information <br /> Use of Well: ❑ Domestic Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑ Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: 0 Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑ Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed:j Test Result: <br /> 1N� L ..s bIMP, M <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: . <br /> Recharge Area: I Recharge Rate: <br /> yv <br /> 1M1s' 'r�"r-mar...-`=�5" > .i�� �;'1.i7..�{?' <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: O /000'i�n„sf Transmission Lines: -/ ,4 <br /> Onsite Well: 4 Pond/Lake: 'a 1A <br /> Sewer Lines: o Stream/River. N A <br /> Animal of Fowl Enclosure: p 5 SID «r �QTu�L <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 pollubon onsite and on adjacent properties,including: <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,map must show location of canals,ditches, pipelines,utility.corridors,and roads within two miles. <br /> I hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: <br /> Information Provided By: Well Driller ❑ Well/Property Owner ❑ Other: <br /> Gun dgnn v3_gi_?n17 9 of <br />