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S A N�1 O A Q U I N Environmental H¢alth Department <br /> COUNTY <br /> IHXtST�N6 WELLS INFORMATION <br /> Total Number Exiatin Wells on Pro art : P/ease complete the in�rma0on below/or every wet/on property.Use entre paper i/needed. <br /> Wali#t Information No information on Walls is available <br /> Use of Well: O Domestic O Irrigation D Small Public Water Supply �Municipal Public Water Supply O Industrial �Stock <br /> O Other: <br /> Total Da th ft: To: From: <br /> Casin Diameter in : Screen Interval(R): To: From: <br /> Pum in Rate m : To: From: <br /> Annual ExMaction Volume(acre-feet: O Estimaletl O Measuretl <br /> S eciflc Ca acit al/min/R <br /> Other Pum in Tests Pertonnetl: Teel Result <br /> Well#2 information <br /> Use of Well: �Domestic �Imlgation D Small Public Water SupPIY O Municipal Public Water Supply �Intlustrlai D Stock <br /> o Other: <br /> Total De th ft: To: From: <br /> Casin Diameter In : Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated � Measuretl <br /> S eciTic Ca acct al/minttt <br /> Other Pum In Testa Pertonnad: Test Result <br /> Well#3 Information <br /> Uae of Well: D Domestic o Irdgellon D Small Public Water Supply O Municipal Public Water Supply �Intlustrial D Stock <br /> 0 otnar: <br /> Total De lh R i To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet p Estima[etl O Measured <br /> S eciflc Ca acit aVmin/R <br /> Olner Pum in Tests Pertormetl: Teel Result: <br /> MAP INFORMATION <br /> A ro'ect site ma must be attached to this form and shall Include the followin information: <br /> Le al lot antl aroel tlimensions. <br /> All well locations on le al lot and aroel with t e and use information shown for each well. <br /> All onsite sewa a treatment s stems,stormwater ontls rocess water ontls antl other sources of otential contamination. <br /> Distance from ro osed well to an otential souroes of ollutlon onsite antl on atl scent ro erties, includln <br /> o Existin or ro osed onsite sewa a treatment s stems wells animal or fowl enclosures [rensmission tines sewer lines. <br /> o Distance from ontls, lakes rivers and streams within 300 feet antl nava able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show location of canals ditches I lines unlit corritlors,antl roads within two miles. <br /> z orz <br />