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SAN JOAQUIN Environ . ital Health Department <br /> COUNTY <br /> ' EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Pro ert : None Please complete the information below for every well on property. Use extra paper if needed, <br /> Well #1 Information <br /> Use of Well : ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ElOther: <br /> Total Depth (ft) : To : From : <br /> Casing Diameter ( in ) : Screen Interval (ft) : To : From : <br /> Pumping Rate pm : 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 #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 ) : Screen Interval (ft) : To : From : <br /> Pumping Rate m : 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 : ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth (ft) : To : From : <br /> Casing Diameter (in ) : Screen Interval (ft) : To : From : <br /> Pumping Rate m : To : From : <br /> Annual Extraction Volume ( acre-feet : ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed : Test Result : <br /> MAP INFORMATION <br /> A project site map 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 /> • All onsite sewage treatments stems , stormwater ponds , process water ponds , and other sources of potential contamination . <br /> • Distance from proposed well to an potential sources of pollution onsite and on adjacent ro erties , including : <br /> o Existing or proposed onsite sewa e treatments stems , wells , animal or fowl enclosures , transmission lines , sewer lines . <br /> o Distance from ponds , lakes , rivers and streams within 300 feet and navigable waterways within one mile , <br /> o For wells below Corcoran clay , map must show location of canals , ditches , pipelines , utility corridors , and roads within two miles , <br /> 2of2 <br />