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SA N �•J O A Q U I N Environmental Health Department <br /> COIJNTY <br /> EXISTING WELLS INFORMATION <br /> Total Number Exisdn Wells on Pm a Pleese complete fhe intormafion Delow for every well on prppert .Uae exNe paper//needed. <br /> Wall#t Infornatlon IJ/A <br /> Uae of Well: �Domestic �Irrigation O Small Public Water Supply O Municipal Public Water Supply O Intlushial O Stock <br /> �Other: <br /> Total De h ft: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual ExNaction Volume(acre-feet: C] Estimated O Measured <br /> S acific Ca acit allmin/f[ <br /> Other Pum In Tests Pertormetl: Test Result: <br /> Well#2 information N/A <br /> Use of Well: �Domestic �Irdga[icn D Small Public Water Supply �Municipal Public Water Supply D Industrial D Stock <br /> �Other: <br /> Total De [h ft: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Ezlrection Volume(acre-tee[: O Estimated � Measuretl <br /> S ecHic Ca acct aVmin/ft <br /> Other Pum in Tests Performed: Test Result: <br /> Well#3 Information wA <br /> Use of Well: O Domestic O Irrigation D Small Public Water Supply �Municipal Public Water Supply � Intlustrial O Stock <br /> D Other: <br /> Total De lh k: To: From: <br /> Casin piamatar in : Screen Interval(ft): To: From: <br /> Pum In Rate m: To: From: <br /> Annual Extraction Volume(acre-feat: O Estimated D Measuretl <br /> 5 acific Ca acit al/min/ft <br /> Other Pum in Tests Performed: Test Result <br /> MAP INFORMATION <br /> A ro act site ma must be attached to this form antl shall include the followin Information: <br /> Le aI lot and aroel dimensions. <br /> All well locations on le al lot and arcel with a and use information shown for each well. <br /> All onsite sewa a treatment s stems stormwater onds, rocess water onds and other sources of otentlal contamination. <br /> Distance from ro osad well to an otentlal sources of ollution onsite and on ad scent ro erties,includin <br /> • o Existin or ro osad onsite sewa a treatment s stems,wells,animal or fowl enclosures transmission lines,sewer lines. <br /> o Distance from onds.lakes, rivers and streams within 300 feat and nevi able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show location of canals ditches i alines utllil corridors antl roads within two miles. <br /> 2 orz <br />