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SANJ O A Q U I N Environmental Health Department <br /> Y <br /> Well#2 Information <br /> :Use o�el �Other: <br /> c ❑Irrigation �10 Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> Total Deq(in): <br /> To: From: <br /> Casing Diame _ ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate To: From: <br /> Annual Extraction Volume(acre-feetl O Estimated ❑ Measured <br /> Specific Capacity(gallminlft): <br /> Other Pumping Tests Performed: lest Result: <br /> Well#3 Information <br /> Use of7Well: Domestic ❑Irrigation [01Small Public Water Supply C1Municipal Public Water Supply ❑Industrial ❑Stock <br /> Other. <br /> Total Depth(ft): !To: From: <br /> Casing Diameter(in): �, ❑Open Bottom or Screen Interval(ft): From:Pumping Rate(gpm): _ From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> FSpecific Capacity(galJminlft): <br /> —therPumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference:_ <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Neares�Syst Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatmeem: ti Transmission Lines: <br /> Onsite Well: S�(.r�) Pond/Lake: V/67- <br /> Sewer <br /> 67-Sewer Lines: w Stream/River. a <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 followincLinformation: - <br /> • Legal 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 proposed well to any potential sources of pollution onsite and on adjacent ro erties,including: <br /> o Existing or proposed onsite sewage treatments stems,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 clay,map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. <br /> t hereby certify that the information l h provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: <br /> Information Provided By: El er F WelllProperty Owner Other: <br /> EHD 4300 12-21-2017 2 or 2 <br />