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WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Data of Reference: <br /> Current Water Tabu 2 L W <br /> Ifohest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: o vt I?,L&owe Recharge Rate: v e, <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: owe. Distance To Nearest(fQ: Onsite: Offsite: <br /> Wastewater Treatment System u4-L Transmission Lines: <br /> Onsde Wel: y v` P bndtLake: <br /> Sewwe rr Lines: �✓�• �' Stneamllbver. <br /> Animal of Fowl Endosum <br /> MAP INFORMATION <br /> A mp of the well location must be attached to this form and shall indude the following information: <br /> • Legal lot and parcel dimensions. <br /> • All well Imhons on N lot and parcel with and use information shown for each wel_ <br /> • Distance from proposed well to an ten6al sources of pollution onsite and on adjacent Roperfies,including: <br /> o Existing or proposed onsite sewage treatment 3ystems.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 day,map must shoe location of canals ditdtes,pipefirm.ufifily corridors,and roads within two miles. <br /> I hereby certify <br /> /that the information 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: :; Date.- <br /> Information <br /> ate:Information Provided By: ❑Well Driller El WeVroperty Owner I]Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />