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SANJOAQUIN Envirvitmental Health Department <br /> - <br /> - -- COU N T Y <br /> EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Property : 1 Please complete the information below for every well on property. Use extra paper if needed. <br /> Well # 1 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 /> CasingDiameter ( in ) : Screen Interval (ft) : To : From : <br /> PumpingRate m : To : From : <br /> Annual Extraction Volume ( acre -feet : ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed : Test Result : <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 ) : Screen Interval ( ft) : To : From : <br /> Pumping Rate m : To : From : <br /> Annual Extraction Volume ( acre -feet : ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed : Test Result: <br /> Well #3 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 ) : Screen Interval ( ft) : To : From : <br /> Pumping Rate m : To : From : <br /> Annual Extraction Volume ( acre -feet : ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed : Test Result : <br /> MAP INFORMATION <br /> A project site map must be attached to this form and shall include the following information : <br /> • <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 /> • All onsite sewage treatments stems , stormwater ponds , process water ponds , and other sources of potential contamination . <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 , rivers and streams within 300 feet and navigable water ways within one mile . <br /> o For wells below Corcoran clay , map must show location of canals , ditches , pipelines , utili y corridors , and roads within two miles . <br /> 2 of 2 <br />