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SAN 0AQUIN - COUNTY.--.._. r, Environmental Health Department Well #2 Information S �� ,,q iqS3. 21 Q �{� ' 7 )omestic ,Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Use of Well: Recharge Area: Recharge Rate: NIA ❑ Other: JA Onsite Well: 9r'OO Total Depth (ft): 0001 SewerLines: To: From: Casing Diameter (in): &" ❑ Open Bottom or Screen Interval (ft): To: From: Pumping Rate (gpm): 7e� To: From: Annual Extraction Volume (acre-feet: X Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well #3 Information omestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Use of Well: ❑ Other: Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): 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: WATER TABLEINFORMATION 5. N, Depth (ft): Source of Reference: Date of Reference: Current Water Table: yIQ �{� ' 7 Highest Water Table: Onsite: Lowest Water Table: Distance To Nearest (ft): Onsite: Recharge Area: Recharge Rate: SITINGINFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: NIA Transmission Lines: AN JA Onsite Well: 9r'OO Pond/Lake: N -�- SewerLines: PJA 2oco4- Stream/River: Animal of Fowl Enclosure: ► I' I A k i l n MAPINFMATION:-:' A map of the well location 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. • 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, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby cern that the i / rmation / have provided is accurate and truthful to the extent reasonably known. Signed: Date: 60/ Information Provided y: /4 Wellrifler ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2