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SAN10 A Q U I N Environm¢ntal H¢alth D¢partment <br /> - - COUNTY - <br /> CX�ST�N6 WELLS INFORMATION <br /> Total Number Existin Walls on Pro art � Please camp/eta the information 6ebw for every well on property.Use entre paper/f needed. <br /> Well#7 Information <br /> Use of Well: �Domestic m Irrigation O Small Public Wafer Supply o Munidpal Public Water Supply O Industrial O Stock <br /> O Other. <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 Extraction Volume(acre-fee[: 20 acre teat ® Estimatetl O Measuretl <br /> S ecific Ca acil al/min/R <br /> Other Pum in Tests Performetl: ODf3 Test Result: None <br /> Well#2 Information <br /> Use of Weli: O Domestic o Irrigation o Small Public Water Supply D Municipal Public Water Supply O Industrial o Stock <br /> O Other: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rale m : To: From: <br /> Annual Extraction Volume(acre-feet: p Estimatetl O Measured <br /> S ecific Ca acct al/min/ft <br /> Other Pum in Testa Performed: Test Result: <br /> Wall#3 information <br /> Uae of Well: �Domestic o IrrigaRon o Small Public Water Supply �Municipal Public Water Supply O Indushlal o Stock <br /> D 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 EMraction Volume(sere-feet: o Esfimatetl o Measuretl <br /> eclRc Ca acct aVmin/it <br /> Other Pum in Tests Pertormetl: Tesl Result: <br /> MAP INFORMATION <br /> A ro'ea site ma must be attached in this form and shall include the followin Information: <br /> L al lot and aroel dimensions. <br /> All well locations on le al lot and amyl with a and use information shown for each well. <br /> All onsite sews a treatment s stems stormwater onds rocess water onds and other sources of otential contamination. <br /> Distance from ro osed well to an otential sources of ollution onsite and on adacent ro erties includin <br /> a o Existin or ro osed onsite sewn a treatment s tams wells animal or fowl enclosures transmission lines sewer lines. <br /> o Distance from onds lakes rivers antl streams within 300 feet and nava able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show location of canals ditches i alines utili corridors and roads within two miles. <br /> z ofz <br />