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SAN J O A Q U I N Environmental Health Department <br /> ---- COUNTY---- <br /> Grectn?ss 9ro�-,t ! <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 INFORMATION <br /> Well Location Address: '�'/dd 7 r/AN sd',✓ City: (L y4. L <br /> Well Location APN: <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: F, �� Applicant Title: d w x�, F o <br /> Applicant Address: 3 S'C� `l e Aj�'� City: <br /> Applicant Phone: cq&q 9"VY T Applicant email: L ����F -?A *q/a5.0 <br /> Property Owner Name: <br /> Property Owner Address: �'g j 0 02 U T City: K e <br /> Property Owner Phone: -I?f Y - Iq S'O Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): Acres to be Served by Well: <br /> Use of Well: ❑ Domestic I)Idrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): J60 <br /> Proposed Well Capacity(gal/ft): O Estimated Pumping Rate(gal/min): p <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: <br /> ❑ Domestic %Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): _ To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): Sa To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />