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SAN- J 0 A Q U I N Environmental Health Department <br /> C O U N T Y----- <br /> Great..,^,, , ;/rows 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 INFORMATION <br /> Well Location Address: 0. ( '2 d City: CSCa� o� <br /> Well Location APN: _ _ q p <br /> Well Latitude: 21� Well Longitude: ?�7 <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: y"� Applicant Title: ID Vve <br /> Applicant Address: 'y� City: y� <br /> Applicant Phone: !?A4,-61 91 Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSEDWELL INFORMATION <br /> Well Total Depth(ft): U Acres to be Served by Well: o. Cn7 <br /> Use of Well: ❑ Domestic e 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): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): N Z <br /> Esti ted Cumulative Extraction Volume before January 1,2020(acre-feet)- <br /> EXISTING WELLS INFORMATION /, <br /> Total Number of Existing Wells on Property: y <br /> Please complete the information below for every well on property. Use extra paper if needed <br /> Well#1 Information <br /> ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> Use of Well: <br /> ❑ Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 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 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />