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SAN JOAQUIN <br />--COUNTY-- <br />h�) 4 <br />Environmental Health Department <br />w <br />y <br />Use of Wel:0mestic <br />ElIrrigation <br />her <br />❑ Small Public Water Supply [IMunicipal Public Water Supply <br />qIndustrial ❑ Stock <br />Total Depth (ft): <br />To: &tO <br />O Open Bottom or Screen Interval (ft): To: <br />To: <br />From: 0 <br />From: <br />From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): y;t) <br />Annual Extraction Volume (acre-feet: 520 <br />Edmated ❑ Measured <br />Specific Capacity (9~):l <br />Other Pumping Tests Perkvned <br />Test Result <br />Well 13 Intomrstion <br />Use of Weg: <br />O Domestic ❑ Irrigation <br />❑ Other. <br />❑ Small Public Water Supply O Municipal Public We* Supply <br />❑ Industrfal O Stock <br />Total Depth (ft): <br />Casing Diameter (in): <br />Pumping Rale (gpm): <br />To: <br />❑ Open Bottom or Saw Interval (ft): To: <br />To: <br />From: <br />From: <br />From: <br />Annual Extraction Volume (acre-feet <br />❑ Estimated ❑ Measured <br />Specific Capacity (DaVmht): <br />Other Pumping Tests Perfomred: <br />Test Result <br />WATER TABLEIB1Cif€�N ` <br />Deptfi (ft): Sours of Rderenoe: Dab of Reference: <br />Current Water Table: <br />Highest Water Table: <br />Lowest Water Table: <br />Recharge Area: Recharge Rate: <br />StTiNG,INFORiON•. � , . <br />DWancs To Nearest (ft): Oneib: offsite: Disbnce To Nearest (ft): Onsib: Ofialta: <br />Wastewater Trestowt syslem: Transmission linea: <br />Onsite Well: Ponaake: <br />Sewer Lines: straamlRiver: <br />Animal of Fowl Endosure: <br />MAP INFORMATION <br />A map of the well location must be attached to this form and shall include the following information: <br />• Legal lot and parcel dimensions. <br />• All well locations on legal lot and parcel with and use information shown for each well. <br />• Distanoe from well to any pollential sources of polkition onsite and on ad' t properties, Including: <br />o Existing or mpsed onsite sewage treatment system, wells animal or fowl enclosures transmission lines sewer fines. <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 coniclors, and roads within two miles. <br />I hereby certify PW the In on I have provided Is accurate and "ful to the extent reasonablyknown. <br />Signed: Date: Y Z -11Fkn <br />Information Provided By: Wel Driller ® Wel/Property Owner ❑ Other. <br />EHD 430012-21-2017 2 01`2 <br />