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SANIOAQUIN COUNTY -- Environmental Health Department Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): To: From: ❑ open Bottom or screen Interval (ft): To: From: _ To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed:1 I Test Result: Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: ., y Distance To Nearest (ft): Onsite: offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: Sewer Lines: Stream/River. Animal of Fowl Endosure: 'lilli 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 I lot and parcel with type and use information shown for each well. • Distance from proposed well to any potential sources of pollullion onsite and on adjacent properties, including: o Existing or MWsed onsite sewage treatment systems, 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 cerft that the " "on l have provided is accurate and tr Signed: Information P ded By: _ell Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2 to the extent reasonably known. _ Date: