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SA N:J O A Q U I N Environmental HealHi Departmenk <br /> COUNTY <br /> EXISTING WELLS INFORMATION <br /> Total Number Exis[in Wells on Pro a Pease comp/e/e the in/ormat/on be/ow/or every we//on property.Use a#ia paper if naetled. <br /> Well#t Information <br /> Use of Well: o Domestic D Irrigation �Small Public Water Supply O Municipal Public Wafer Supply O Industrial o Stock <br /> 0 otner: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: � <br /> Pum in Rate m : To: From: <br /> Annual Ertractlon Volume(acre-feet: O Estimated D Measured ' <br /> S ecfic Ca aci al/minttt <br /> Other Pum in Tesfs Performed: Test Result <br /> Well#2 Information i <br /> Use of Well: O Domestic O Imgatlon O Small Public Water Supply O Municipal Public Wa[ar Supply O Industrial D Stock <br /> o Other: <br /> Total De th R: To: Fmm: <br /> Casin Diameter In : Screen Interval(ft): To: From: � <br /> Pum in Rate m: To: From: <br /> Annual EMrection Volume(acre-feet: O Estimated O Measured <br /> ecific Ca aci al/min/R <br /> ONer Pum in Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: O Domestic D Irtigatlon O Small Public Water Supply D Municipal Public Water Supply �Intlustrial D Stock <br /> o Other: <br /> Total Da h R: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: p Estimated � Measured <br /> S ecrtc Ca aci al/min/R <br /> OMer Pum in Tests Pertortned: Test Result: <br /> MAP INFORMATION <br /> A rn'ect site ma must be attachetl 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 aroel with a and use information shown for each well. <br /> All onsite sewa a treatment s stems stortnwater onds, rocess water onds and other sources of otential contamination. <br /> Distance from ro osetl well to an otential sources of ollution onsite and on ad scent ro erties, includin <br /> o Existin or ro osetl onsite sewa a treatment s stems,wells,animal or fowl enclosures transmission lines,sewer Ilnes. <br /> o Distance from onds, lakes rivers antl streams within 300 feet antl nevi able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show location of canals,tlitches, i alines,utili corridors antl roatls within two miles. <br /> z otz <br />