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SAN Q A Q Q N Environmental Health Department <br /> COUNTY <br /> ` Greotness prows f =r <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 /> 2 5 \\ <br /> WELL LOCATION AN4 OWNER INFORMATION <br /> Well Location Address: / w City: ;n <br /> Well Location APN: 0, (-,-1 DACo <br /> Well Latitude: 3 Y,DQa,6 y Well Longitude: !aO. 69/ <br /> Flood Plain Designation: Well Elevation: / 6 j'ft <br /> Applicant Name: w j kApplicant Title: e r <br /> Applicant Address: wj 6..� City: (,Oe( ; <br /> Applicant Phone: d,©'2_ 3SY_ C S Applicant email: <br /> Property Owner Name:QLI r4aL en DA <br /> Property Owner Address: v p f ,(L City: G,,L/- "� <br /> Property Owner Phone: 8 p _ Property Owner email: <br /> �a✓` PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): Acres to be Served by Well: itp—lL-) <br /> f � <br /> Use of Well: ❑ Domestic 911'r—rigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): 2,o? Estimated Pumping Rate(gal/min): dQ <br /> Anticipated Pumping Schedule(gal/day): 1 kAl OD�114 Estimated Annual Extraction Volume(acre-feet): 1 oG <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): l <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: <br /> ❑ Domestic El Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): 5oO To: From: <br /> Casing Diameter(in): 9'It, ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 0 p;,, UnKnvj--ri To: From: <br /> )C Annual Extraction Volume(acre-feet: /04, X Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): ,4,,7 <br /> Other Pumping Tests Performed: AV to 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 />