Laserfiche WebLink
Jh t�1 1 O A O I 1 I �1 Environ ntal Health Department <br /> Lt l�1 l Lt 1.1 'Y �XISTtNG WELLS INFORMATION <br /> Total Number Existin Wells on Pro art Please comp/efe the information below for every well on property Use entre peperil needed. <br /> Wall#f Information <br /> Use of Well: O Domea[ic O Irdgellon O Small Public Water Supply D Municipal Public Water Supply O Intluatrial O Stock <br /> O Ofher: <br /> Total Da th ft: To: From: <br /> Casio Diameter in : Screen Interval(ft): To: From: <br /> Pum In Rate m: To: From: <br /> Annual Extraction Volume(acre-feet O Eatimatetl � Measuretl <br /> S ecific Ca aci al/min/ft <br /> Other Pum in Teats Performetl: Test Result <br /> Well#2 Information <br /> Use of Well: O Domestic D Irrigation D Smell Public Water Supply � Municipal Public Water Supply O Intluatrial �Slock <br /> �Other: <br /> Total De [h ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: O Eatimatetl O Measuretl <br /> S ecifc Ca aci al/min/R <br /> Other Pum in Tests Pertortnetl: Test Result <br /> Well#3 Information <br /> Use of Well: o Domestic o Irrigation O Small Public Water Supply �Municipal Public Water Supply O Intlustnal o Stock <br /> o Other: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rata m : To: From: <br /> Annual Extraction Volume(acre-feet: � Estimated O Measuretl <br /> S ecific Ca aGt al/min/ft <br /> Other Pum in Tests Performed: Test ResulC <br /> MAP INFORMATION <br /> A ro'ect site ma must be attached to this forth and shall include the followin information: <br /> Le al lot and aroel 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 tams,stortnwater onds rocess water onds and other sources of otential contamination. <br /> Distance from ro osed well[o an otential sources of ollution onsite and on ad'acent ro erties, includin <br /> • o Existin or ro osetl onsite sewa a treatment s stems wells animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance tram onds, lakes, overs and streams within 300 feet and nevi able wafer wa s within one mile. <br /> o For wells below Corcoran cla ma must show location of canals tlitches i alines utili corridors,and roads within two miles. <br /> 2 of 2 <br />