Laserfiche WebLink
SA N�10 A Q U I N Environmental Health Department <br /> C O U N T Y------ <br /> YVell#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(gaVminift): <br /> Other Pumping Tests Performed: Test Resuft: <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(n): ❑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(gallmintit): <br /> Other Pumping Tests Performed: Test Resuft: <br /> Depth(ft): Souree of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> Distance To Nearest(ft): Ons": Ofisite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River. <br /> Animal of Fowl Enclosure: <br /> WN <br /> ::; rS y':r� `.�c,�'C` �:,v <br /> IM,.w t��., ,;n. a <br /> A map of the well location must be attad►ed to this form and shall include the following information: <br /> • Legal lot and parcel dimensions. <br /> • Al well locations on al lot and parcel with type and use information shown for each well. <br /> • Distance from proposed well to any potential sources of pollurtion onsite and on adjacent properties,indudin : <br /> o E)dsbng or proposed onsde sewage treabyent systems,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 day,map must show location of canals,ditches,Opelines,utility corridors,and roads within two miles. <br /> I hereby c Mo►matiton l have prov orate and budiful to the extent reasonably known. <br /> Signed: i Date:Vi <br /> Information Provided By: Well Dnw ❑ waftperty owner ❑ Othec <br /> EHD 430012-21-2017 Z of 2 <br />