WP0042830 - Laserfiche WebLink

Home Browse Search

SAN.JOAQUIN COUNTY Environmental Health Department Well #2 Information Depth (ft): Source of Reference: Dateof Reference: Use of Well-fo❑ Domestic ❑ Irrigation Other ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): Casing Diameter (in): Pumping Rate (gpm): To: ❑ Open Bottom or Screen Interval (ft): To: To: From: From: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gaVmin/ft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other. ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock 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: I ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: -WATE it"O"1 A'f�f3l ,r� Depth (ft): Source of Reference: Dateof Reference: Current Water Table: sZ f�.7rtr�IrlK Com- r+Z1 Highest Water Table: Onsite Well: Lowest Water Table: Recharge Area: Recharge Rate: S.�;E I!!:!'��Gs?'•"'�a`i�i, k7. � ✓'..o ,+L'r" s a �h.. � ..e!:.�-- c, ,.i; •�'_. f w Distance To Nearest (ft): Onslte:' Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: aERL Stream/River. Animal of Fowl Enclosure: "��%1r' ,{l,�EP� ,7RZ •Yr.-. �,s'?4.• 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 E)dsbnq 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 certify that the Information 1 have provided is accurate and truthful to the extent reasonably known. Signed: Information Provided By: Well Driller ❑ Well/Property Owner ❑ Other. EHD 4300 12-21-2017 2 of 2 Date: