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SAN 10AQ U I N Environmental Health Department <br /> --COUNTY---- <br /> Greatness grows here. <br /> New Well Information <br /> Pursuant to California \Nater 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: 40 dl i 1Y City: <br /> Well Location APN: 0513�V.� <br /> Well Latitude:31-15-L,90-7 Well Longitude: —'A/./ 5177 <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: ), �ro S f Applicant Title: <br /> Applicant Address: Pdb,,l <br /> 1.7yCity: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: <br /> Property Owner Phone: p�_ a_(p q,Z3 Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft):I I ybC� Acres to be Served by Well: <br /> Use of Well: ❑ Domestic gYtl'rigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Depth of Corcoran Clay(ft): �IA <br /> Proposed Well Capacity(gal/ft): Estimated Pumping Rate(gal/min): AM <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): ilk <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: ❑ 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): To: From: <br /> Annual Extraction Volume(acre-feet:1 ❑ 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 />