WP0045300 - Laserfiche WebLink

Home Browse Search

SANJ O A Q U I N Environmental Health Department C01,JN i Y Well#2 Information Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Municpal Public Water Supply ❑Industrial ❑Stock ❑Other -- -- --- Total Depth(ft): To: From: -_ Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: _ Pumping Rate(gpm):I To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured) Specific Capacity(gallminfft): -- --- — - Other Pumping Tests Performed: _ Test Result: Well#3 Information Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industnal ❑Stock _❑_Other: Total Depth(ft): To: From: Casing Diameter(in): _ ❑Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/minlft): Other Pumping Tests Performed:1 Test Result WATER TABLE INFORMATION Depth(ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: -- Lowest Water Table: Recharge Area: j Recharge Rate: SITING INFORMATION 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 Enclosure: MAP INFORMATION A map of the well location must be attached to this form and shall include the folkyMng information: • Legal lot and parcel dimensions. • All well locations on legal lot and paroel 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: *Existing or proposed onsite sewage treatment systems,wells,animal or fowl enclosures,transmission lines,sewer lines. o Distance from porids,lakes,and streams within 300 feet. o For wells below Corcoran clay,map must show 6 cation of canals,ditches,pipelines,utility corridors,and roads within two miles. i hereby certify that the inform ave provided is accurate and truthful to the extent reasonably known. Signed: Date: 00•Z1. 2�3 Informs' vided By: )kWeil Driller O Well/Property Owner ❑ Other. _HD 4300 12-21-2017 90f?