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SANJ O A Q U I N Environmental Health Department <br /> - C O U N T Y--- <br /> EXISTING WELLS INFORMATION <br /> Total Number-Existing'Wells on Pro erty. N 1A t Please complete the informafron below for every well on property,Use extra paper rfneeded. <br /> Well 91 Information ' <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth ft: To: From: <br /> Casing Diameter(in):. Screen Interval.(i):.To: From.- <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft: <br /> Other Pumping Tests Performed:1 I Test Result: <br /> Well#2 Information <br /> Use of Well: D]Domestic II Irrigation IDSmall.Public Water Supply D,Municipal Public Water:Supply ll Industrial O.Stock <br /> ❑Other: Kf/A <br /> Total Depth ft: To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> S ecific Caps (gallminlffl- <br /> Other Pumping Tests Perfor ed:1 Test Result <br /> Well#3 Information <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Tota!Depth(ft):1 , To: From: <br /> Casing Diameter(in): Screen Interval(ft) To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measure <br /> Specific Ca ac' al/min/ft: <br /> Other Pumping Tests Performed:1 Test Result <br /> AT# <br /> A project site map must be attached to this form and shall include the following information: <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 /> • All onsite sewage treatment systems,stormwater ponds,process water ponds,and other sources of potential contamination. <br /> • Distance from. ro o._sed.wPIl.to any p0ential sources of.pollution onsite and on adjacent propprtips,incluctin <br /> o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission Tines,sewer fines. <br /> o Distance from ponds,lakes,rivers and streams within 300 feet and navigable water was within one mile. <br /> o For wells below Corcoran clay,map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. <br /> 2of2 <br />