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SANJOAQUIN p <br /> Environmental Health Department <br /> COUNTY <br /> +rorr1' Greatness grows here. <br /> New Well Information <br /> Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit <br /> the following required information, to the extent that can be reasonably known. The Environmental Health Department <br /> must collect this information before a new well permit is issued and must post the information on the Department's <br /> website for public information. <br /> EXEMPTION CRITERIA <br /> Well meets the following Exemption: <br /> Well not located in a critically overdrafted basin. <br /> Well owner will be a de minimis extractor: maximum two acre-feet or less per year being extracted for domestic <br /> purposes only. <br /> Replacement well with same extraction as the existing well that it is replacing. The existing well must be <br /> destroyed under permit. <br /> Public agency that substantially meets or exceeds these requirements through another requirement of the law. <br /> In order to be exempt, the applicant shall document the laws that substantially meet or exceed these <br /> requirements and how the requirements of those laws were met. <br /> A cit or county municipal well to provide water supply solely for residents of the city or county. <br /> WELL LOCATION AND OWNER INFORMATION , <br /> Well Location Address: IS So 47 V/c o-y Ad I City: IdX <br /> Well Location APN: -d <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Sr,ch 0 A licant Title: G w <br /> Applicant Address: p,6, f3&y -o City: Qa"a <br /> Applicant Phone: t4 in i_j_ S 0 A licant-mail- <br /> Property <br /> mail:Pro e Owner Name: <br /> Property Owner Address: CitTF <br /> Property Owner Phone: Pro ert Owner email: <br /> PROPOSED WELL.INFORMATION <br /> Well Total Depth(ft): O b Acres to be Served by Well: /Q a <br /> Use of Well: ❑ Domestic XIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay ft: <br /> Proposed Well Capacity (gal/ft): leoep Estimated Pumping Rate al/min): o oep <br /> Anticipated Pumping Schedule al/da Estimated Annual Extraction Volume acre-feet: (�G <br /> Est ated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INFORMATION <br /> Number Existing Wells on Property: I 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 ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth ft: SG To: From: <br /> Casing Diameter in : ElOpen Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: -Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed: Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 5205 I T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />