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SAN J O A Q U I N Environmental Health Oepart—nt <br /> C O U N T Y <br /> lX�8T�NCi WELLS INFORMATION <br /> Total Number Existing Wells on Proi Please complete the information below for every well an property.Use extra paperifneeded. <br /> - Well*1 Information <br /> Use of Well: a Domestic a Irrigation D Small Public Water Supply M Municipal Public Water Supply ID Industrial O Stock <br /> O Other. <br /> Total Depth(ft):[ To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rata m : To: From: <br /> Annual Extraction Volume(acre-feet:j ED Estimated D Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping <br /> um in Tests Perforrned: Test Result: <br /> Wall#2 Information <br /> Use of Well: O Domestic O Irrigation O Small Public Water Supply E3 Municipal Public Water Supply E.Industrial 0 Stock <br /> Ej Other: <br /> Total Depth ft: To: From: <br /> Casing Diameter in : Screen Interval(ft): To: From: <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feat: EJ Estimated O Measured <br /> Specific <br /> Capacity al/min/ft <br /> Other Pum in Tests P-rlormed:l Test Result _ <br /> Well#3 Information <br /> Use of Well: E3 Domestic L-1 Irrigation O Small Public Water Supply O Municipal Public Water Supply O Industrial E3 Stock <br /> E3 Other: <br /> Total Depth 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 M Measured <br /> S ecific Ca aci al/min/ft <br /> Other Pum ping Tests Perormed:j Test Result: <br /> MAP INFORMATION <br /> A 'act site ma must Ue attached to this form and shall include the followin information: <br /> Le al lot and arcel dimensions. <br /> All well locations on le al lot and arcel with a and use information shown for each well. <br /> All onsite sewa a treatment s stems,stormwater ponds, rocess water onds and other sources of otential contamination. <br /> Distance from ro osed well to an otential sources of poll, onsite and on ad'acent roernes,irx:ludin <br /> o Existingor ro ed onsite sewa a treatment system wells,animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from onds,lakes, rivers and streams within 300 feet and navi able water ways within one mile. <br /> o For wells below Corcoran clay,ma must show location of canals,ditches,pipelines,utilitycorridors,and roads within two miles. <br /> 2 oft <br />