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SA N J O A Q U I N Environmental Health Department <br /> COUNTY— <br /> Well#2 Information <br /> Use of Well: <br /> Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): P ❑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: <br /> ❑Domestic Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ElOpen Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: Estimated ❑ Measured <br /> Specific Capacity(gallmin/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TAKE INFORMATION r Date of Reference: <br /> Depth(ft): Source of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: ;Recharge <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Pond/Lake: <br /> Onsite Well: <br /> Stream/River: <br /> Sewer Lines: <br /> Animal of Fowl Enclosure: <br /> MAR.INFORI1dATI0N <br /> A ma of the well location must be attached to this form and shall include the following information: <br /> • Le al lot and parcel dimensions. <br /> • All well locations on le al lot and arcel with a and use information shown for each well. <br /> • Distance from proposed well to an tential sources of pollution onsite and on adjacent ro erties,including: <br /> o Existing or proposed onsite sewage treatment 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 clay,ma must show location of canals,ditches,pipelines,utilitycorridors,and roads within two miles. <br /> 1 hereby certi that th information 1 have provided is accurate and truthful to the extent reasonably known. <br /> Date: ��•L�•Z <br /> Signed: <br /> Information Provided By: Well Driller O WelUProperty Owner i] Other: <br /> EHD 4300 12-21-2017 <br /> 2of2 <br />