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/ P41UIN� Q7o' c°Z�, SAN _J OAQ U I N Environmental Health Department !� COUNTY e � q< _J New Well Information Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit the following required information, to the extent that can be reasonably known. The Environmental Health Department must collect this information before a new well permit is issued and must post the information on the Department's website for public information. EXEMPTION CRITERIA Well meets the following Exemption: Well not located in a critically overdrafted basin. JWell owner will be a de minimis extractor: maximum two acre-feet or less per year being extracted for domestic purposes only. Replacement well with same extraction as the existing well that it is replacing. The existing well must be destroyed under permit. Public agency that substantially meets or exceeds these requirements through another requirement of the law. In order to be exempt, the applicant shall document the laws that substantially meet or exceed these requirements and how the requirements of those laws were met. A city or county municipal well to provide water supply solely for residents of the city or county. WELL LOCATION AND OWNER INFORMATION Well Location Address: S City: Well Location APN: 3-2 u- Well Latitude: Well Lon itude: Flood Plain Designation: Well Elevation: Applicant Name: Applicant Title: Applicant Address: Cit : Applicant Phone: Applicant email: Property Owner Name: Property Owner Address: Cit Property Owner Phone: Property Owner email: PROPOSED WELL INFORMATION Well Total Depth(ft):1 Acres to be Served by Well: Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Depth of Corcoran Clay(ft): Proposed Well Capacity (gal/ft): Estimated Pumping Rate (gal/min): Anticipated Pumping Schedule (gal/day): Estimated Annual Extraction Volume acre-feet): Estimated Cumulative Extraction Volume before January 1,2020 acre-feet): EXISTING WELLS INFORMATION Number Existing Wells on Property: I Please complete the information below for every well on property. Use extra paper if needed, Well#1 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter (in : ❑ Open Bottom or Screen Interval(ft): To: From: Pumping Rate pm : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed: Test Result: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com