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S A N ,,J Q A Q U I N Environmental Health Department <br /> COU NTY--- <br /> ,r,�;a:;� Greotness grows here. <br /> New Well Information <br /> Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption <br /> criteria must submit the following required information, to the extent that can be reasonably known. <br /> The Environmental Health Department must collect this information before a new well permit is <br /> issued and must post the information on the Department's website for public information. <br /> WELL LOCATION AND OWNER INFORM TION <br /> 4 . <br /> Well Location Address: qny <br /> 4C4& City: <br /> Well Location APN. <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: ] Well Elevation: <br /> Applicant Nama 1 Applicant Title: <br /> Applicant Address: City: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: / 1 <br /> Property Owner Address: G` t�dwCity: <br /> Property Owner Phone: _ Property Owner email: <br /> PROPOSED WELL INFORMATION ? <br /> Well Total Depth(ft): Acres to be Served by Well: <br /> Use of Well: ❑ Domestic Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): q0 v Estimated Pumping Rate(gal/min): L(O 0 <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): (� <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INFORMATION <br /> Total Number of Existing Wells on Property: <br /> Please complete the information below for every well on property. Use extra paper if needed <br /> Well#1 Information <br /> Use of Well: ElDomestic D Irrigation ElSmall Public Water Supply ElMunicipal Public Water Supply 13Industrial ElStock <br /> ❑ Other: <br /> Total Depth(ft): 23 V To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: 440 YFrom: <br /> Pumping Rate(gpm): f ,t<µS� To: From: <br /> Annual Extraction Volume(acre-feet: /, ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): �r <br /> Other Pumping Tests Performed: /, I Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />