Laserfiche WebLink
SANJ O A Q U I N ;.t(3EnvironmentaI Health Department <br /> Well#2 Information <br /> Use of WellTIC] <br /> Domestic C)Irrigation ❑Small Public Water Supply :1 Municipal Public Water Supply ❑Industrial ❑Stock <br /> Other: <br /> Total Depth(ft)] ? To: FGN, From: <br /> Casing Diameter(in): a' ❑Open Bottom or Screen Interval(ft): To: - From: <br /> Pumping Rate(gpm): boo To: From: <br /> Annual Extraction Volume(acre-feet: J, n 10 Estimated ❑ Measured <br /> Specific Capacity(gallmin/ft): <br /> Other Pumping Tests Performed: ( NS Test Result <br /> Well#3 Information <br /> Use of Well: ❑Domestic lb Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): 5'ao To: From: <br /> Casing Diameter(in): Ia ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 6L To: From: <br /> Annual Extraction Volume(acre-feet: 1,;t0 _ ❑ Estimated ❑ Measured <br /> Specific Capacity(gallminlft): <br /> Other Pumping Tests Performed: Test Result:! <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 5� <br /> Highest Water Table: I Lf o <br /> Lowest Water Table: G <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: S�,1.,` v-' t Transmission Lines. <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River /BO ti <br /> Anima!of Fowl Enclosure: N N <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and shall include the following information: <br /> • <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: I <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 /> I hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: >> Date: <br /> Information Provided Ely: ❑ Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />