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SANJ O A Q U I N Environmental Health Department <br /> ----COUNTY-- <br /> Well#2 Information <br /> Use of Well: ❑Domestic Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): t U ❑Open Bottom er6creerrtnter ": To: From: <br /> Pumping Rate(gpm): r] ' To: From: <br /> Annual Extraction Volume(acre-feet: Estimated ❑ Measured <br /> Specific Capacity(gaUminlft): <br /> Other Pumping Tests Performed: _ _ _Test Result: <br /> Well#3 Information <br /> Use of Well: <br /> OS mestic ❑Irrigation ❑Small Public Water Su ly 13 Municipal Public Water Supply Industrial ❑Stock <br /> ❑Othe. <br /> Total D (ft): To: Fr <br /> Casing DiameterX, ❑Open Bottom or Screen Intery ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/minlft): <br /> Other Pumping Tests Performed: Test R It: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 4- <br /> Highest Water Table: 3 1 <br /> Lowest Water Table: 3 <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: use 5-e Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: O y,, o '�,� Stream/River. <br /> Animal of Fowl Enclosure: tj a <br /> MAP INFORMATION <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 /> • All well locations on legal lot and parcel with type and use information shown for each well. <br /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties,including: <br /> o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran clay,map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. <br /> I hereby certify that <br /> /thee information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: <br /> Date: 6/16/2023 <br /> Information Provided By: ❑ Well Driller [Well/Property Owner ❑ Other: <br /> EHE 4300 12-21-2017 2 of 2 <br />