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S'A N J O A Q U I N Environmental Health Department <br /> GOUTY <br /> OX_S-FIN43 WELLS INFORMATION <br /> Total Number ExistingWells on Pro a Please complete the Information below for every wsH on property. Use extra paper ifneeded. <br /> Well#1 Information <br /> Use of Well: O Domestic Ukirrigation O Small Public Water Supply M Municipal Public Water Supply O Industrial O Stock <br /> E3 Other: <br /> Total De th ft: To: From: <br /> Casing Diameter in : O` Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feat: O Estimated M Measured <br /> Specific Capacity al/min/ft: <br /> Other Pumping Tests Performed: Test Result: <br /> Well#2 Information <br /> Use of Well: C3 Domestic O Irrigation O Small Public Water Supply O Municipal Public Water Supply O Industrial 0 Stock <br /> O Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter (in): Screen Interval(ft): To: I From: <br /> Pumping Rate m : To: From: <br /> tin e <br /> Annual ExtracoVolum (acre-feet: p Estimated Cl Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pum In Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: -Domestic O Irrigation O Small Public Water Supply o Municipal Public Water Supply C3 Industrial Cl Stock <br /> M Other: <br /> Total Depth ft): To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: E3 Estimated O Measured <br /> Secific Capacity al/min/ft, <br /> Other Pum in 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 any potential sources of pollution onsite and on adjacent properties, including: <br /> o Existing or p7roposed onsite sewage 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 water ways 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 /> 2 oft <br />