SU0012668 - Laserfiche WebLink

Home Browse Search

SAN _JOAQUIN -----COUNTY Environmental Health Department Well #2 Information Use of Well: 0 Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): -..:. ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): Offsite: To: From: Pumping Rate (gpm): Offsite: To: From: Annual Extraction Volume (acre-feet: .p ❑ Estimated ❑ Measured Transmission Lines: Specific Capacity (gal/min/ft): + Onsite Well: N Other Pumping Tests Performed: + Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gaVmin/ft): 41cwt 't Other Pumping Tests Performed: Test Result: WATER TABLEriNFORMATION: .: . Depth (ft): Source of Reference: Date of Reference: Current Water Table: 10' Lines of Equal Depth to Groundwater 1997 Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION 1 -..:. Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: N .p 4ow; r Transmission Lines: NIP + Onsite Well: N A + Pond/Lake: ki 1W 4 OX t Sewer Lines: NJA 4 Stream/River: Animal of Fowl Enclosure: N'l A 41cwt 't :MAP INFORMATION A map of the well location must be attached to this form and shall include the following information: • Legal lot and parcel dimensions. • All well locations on legal lot and parcel with type and use information shown for each well. • Distance from proposed well to any potential sources of pollubon onsite and on adjacent properties, including: o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. 1 hereby ce t t the inf ation I have provided is accurate and truthful to the extent reasonably known. tt l Signed: �•`ZY' 1.��.�, Date: Information Provided By: X, Well Driller ❑ Well/Property Owner ❑ Other: _ EHD 4300 12-21-2017 2 of 2