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SANJ O A Q U I N Environmental Health Department <br /> _ "�j �. <br /> Well#2 Information <br /> j ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial n Stock <br /> Use of Well: <br /> ❑ Other: <br /> Total Depth (ft): To: _ From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated a Measured <br /> Specific Capacity(gal/min/ft): _ <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> f C Domestic [I Irrigation ❑ SmNubkr Supply ❑ Municipal Public Water Supply ❑ Industrizl ❑ Stock <br /> Use of Well:, Other:Total Depth(ft): To: From:Casing Diameter(in) or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet. ❑ Es ated C Measured --1—_ <br /> Specific Capacity(gaUminlft)_ <br /> Other Pumping Tests Performed:, Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table /00/ _ ���-7 _ <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> --- <br /> Distance To Nearest(ft): ( Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: I Transmission Lines: <br /> Onsite Well. (053' Pond/Lake. 3 /apo <br /> ' <br /> 11- <br /> Sewer Lines. 1(e- Stream/River: i <br /> _ 1050 -�Yto�c� ---- - _- '. <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 /> • Le al 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 ro osed well to an otential sources of pollution onsite and on adjacent properties, including: <br /> c Existing or proposed onsite sewage treatment systems, wells, animal or fowl enclosures,transmission lines, sewer lines. <br /> o Distance from ands, lakes, and streams withir. 300 feet. <br /> o For wells below Corcoran cls, map must show location of canals ditches pipelines utility corridors, and roads within two miles_ <br /> 1 hereby certify that the information 1 have rovide/d isaccurateand truthful to the extent reasonably known. <br /> Signed: 1 % �� f' Date: <br /> Information Provided By: ❑ Well Driller Well/Property Owner ❑ Other: <br /> FHD 4300 12-21-2017 2 of 2 <br />