Laserfiche WebLink
SA I1 J O A Q U I N Environmental Health Department <br /> COUNTY-- <br /> WeU 82 Information <br /> Use of Wei: ❑Domestic ❑lrigabon O Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(it): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(9Pm): To: From: <br /> Annual E&acfim Vokme(acre4qet ❑ Estimated ❑ Measuired <br /> Specitic Capacity(gaYi i*): <br /> Other P rnpM Tests Performed: Test Result <br /> Wei 83 kiorn adon <br /> Use of Viet O Domestic ❑krigation O Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑tither: <br /> Total Depth(ft): To: From: <br /> Casing DiarrI(in): ❑Open Bodoni or Screen Interval(ft): To: From: <br /> Pumping Rate(cpm): To: From: <br /> Annual Extraction Vol me(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(gaYminAt): <br /> 011ier Pumping Tests Pub7ned:1 Test Result: <br /> 3 <br /> Y <br /> Deplfr If ft Source of Reh"nw: Date of Reference: <br /> Current water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Aron: Recharge Rate: <br /> , r <br /> Distance To Nearest(ft): onsite: Offsite: Distance To Nearest(ft): Onsite: offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: StreaMRiver <br /> Animal of Fowl Enclosure: <br /> A map of the well location must be attached to this form and shall include the following information: <br /> • Legal lot and parcel dimensions. <br /> • AN well bcadorts on kjal lot and parcd with tyLx and use information shown for each well. <br /> • Distance from poposed well to any ppontial sources of pollution onsite and on adjamtproperfies,indudi : <br /> 0 ExistkV or proposed onsite sewage treatment systerns,wells,animal or fowl enclosures,transmission lines,sewer lines. <br /> o DmWnce from ponds,lakes,and streams within 300 feet <br /> o For wells below Corcoran clay,rnap must show bcation of canI ditdm,pipelines,util ooridors,and roads within two miles. <br /> I hereby certify the 1 have pro ' ' accurate and&uthfW to the extent reasonably known. <br /> Signed: Date: ��• ` � 2� <br /> Information y: Well DriNer ❑ WeWPropeq Owner ❑ Other. <br /> EHD 4300 12-21-2017 2 of 2 <br />