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SA N BJ O A g U I N Enviror....ental Health Department <br /> GOU NTY <br /> CX�STtNG WELLS INFORMATION <br /> Total Number Existin Wells on Pro e 1 Please cpm ate the/nformallon below fw every wet/on property.Use exha paper ifneeded. <br /> Well a1 Information <br /> Use of Well: a DomesLc O Imgatlon O Small Public Water Supply O Municipal Public Water Supp1Y O IntlusWal O Stock <br /> s Other:Private <br /> Total De lh ft: unknown To: From: <br /> Casin Diameter in : 6" Screen Interval(ft): To: From: <br /> Pum in Rate m: is To: From: <br /> Annual Extraction Volume(acre-feet:c 2 acre feet a Estimatetl O Measured <br /> S eciftc Ca act al/min/ft: no cast <br /> Other Pum in Testa Perforned: none Teat Result: <br /> Wall#2 lnformatlon <br /> Use of Well: O Domeagc O Irrigation O Small Public Water Supply o Munidpal Public Water Supply O Industrial O Stock <br /> o Other: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: i <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated D Measured <br /> S eciftc Ca aci el/min/ft <br /> Other Pum In Testa Pertormed: Tea[Result: <br /> Well fp Information <br /> Use of Well: �Domestic D Irrigation D Small Public Wafer Supply O Municipal Public Water Supply D Intlustrial �Stock <br /> O Other: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Sereen interval(ft): To: From: <br /> Pum in Rata m: To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated O Measured <br /> S ecific Ca i al/min/ft <br /> OMar Pum in Tests Pertonned: Test Result: <br /> MAP INFORMATION <br /> A ro'ect site ma must be attached Lo this form and shall include the followin information: <br /> L"e al bt and aroel dimensions. <br /> All well locations on I al lot and arcel with a and use Information shown for each well. <br /> All onsite sews a treatment s stems stortnwatar onds rocess water onds,and other sources of obentiel wntamination. <br /> Distance from ro osetl well to an otential spumes of ollution onsite antl on adacent ro erties Inclutlin <br /> o Existin or ro peed onsite sews a treatment s stems wells,animal or fowl enclosures t2nsmission lines sewer lines. <br /> o Distance from onds, lakes, rivers and streams within 300 feet 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, utili corridors,and roads within two miles. <br /> zorz <br />