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fl-A Ljr1-{ <br /> SAN JOAHIN <br /> ;P' E 3Environmental Health Department <br /> COUNTY <br /> Well#2 Information <br /> Use of Well: ❑Domestic Irrigation ❑Small Public Water Supply :1Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): ? To: .Lt-KA.,, From: <br /> Casing Diameter(in): a' ❑ Open Bottom or Screen Interval(ft): To: - From: <br /> Pumping Rate(gpm): E,00 To: From: <br /> Annual Extraction Volume(acre-feet: r 1M Estimated ❑ Measured <br /> Specific Capacity(gallmin/ft): <br /> Other Pumping Tests Performed:1 i,p Tb ,,rC( ,j ,[T4,rvS Test Result:1 <br /> Well#3 Information <br /> Use of Well: ❑Domestic 6 Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): Id ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 6(;,j To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(galimin/ft): <br /> Other Pumping Tests Performed:1 Test Result: <br /> WATER TABLE INFORMATION <br /> j Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: I o <br /> Lowest Water Table: 17Q <br /> Recharge Area: 1 1 Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: 5 P h'L U4 Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: 4 Stream/River x(00 <br /> Animal of Fowl Enclosure <br /> MAP INFORMATION <br /> A map of the well location 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 /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br /> o Existing or proposed onsite sewage treatments stems,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, map must show location of canals,ditches, pipelines, utility corridors,and roads within two miles. <br /> 1 hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: SII Date: V-/? -1 P <br /> Information ProvidecrBy: ❑ Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />