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SANJOAQUIN Environmental Health Department COU N T Y — EXISTING WELLS INFORMATION Total Number Existing Wells on Property : 12 I Please complete the information below for every well on property. Use extra paper if needed. Well #1 Information Water well on APN 931005 as depicted on attached Figure 1 , Well and Septic System Locations Use of Well ; ElDomestic ElIrrigation ElSmall Public Water Supply 1:1Municipal Public Water Supply ® Industrial ❑ Stock ❑ Other : Total Depth (ft) : Unknown To : Unknown From : Casing Diameter ( in ) : Unknown Screen Interval (ft) : To : Unknown From : Pumping Rate gpm : Unknown To : Unknown From : Annual Extraction Volume ( acre -feet : < 1 a Estimated ❑ Measured Specific Capacity (gal/min/ft): unknown Other Pumping Tests Performed : Unknown Test Result : Well #2 Information Water well on APN 9310024 as depicted on attached Figure 1 , Well and Septic Locations Use of Well ; a Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other : Total Depth (ft) : Unknown To : Unknown From : Casing Diameter ( in ) : 8 Screen Interval (ft) : To : Unknown From : Pumping Rate pm : Unknown To : Unknown From : Annual Extraction Volume ( acre -feet : 5 t0 10 e Estimated ❑ Measured Specific Capacity (gal/min/ft): unknown Other Pumping Tests Performed : Unknown Test Result : N /A Well #3 Information Use of Well : ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other : Total Depth (ft) . To : From : Casing Diameter ( in ) , Screen Interval (ft) : To : From : Pumping Rate gpm : To : From : Annual Extraction Volume ( acre -feet : ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed : Test Result : MAP INFORMATION A project site map 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 . • All onsite sewage treatments stems , stormwater ponds , process water ponds , and other sources of potential contamination . • Distance from proposed well to any potential sources of pollution 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 , rivers and streams within 300 feet and navigable water ways within one mile . o For wells below Corcoran clay , map must show location of canals , ditches , pipelines , utility corridors , and roads within two miles .