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SAN J OA Q U I N Environmental Health Department COUNTY- New Well Information Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit the following required information, to the extent that can be reasonably known. The Environmental Health Department must collect this information before a new well permit is issued and must post the information on the Department's website for public information. WELL LOCATION AND OWNER INFORMATIO Well Location Address: doh City: Well Location APN: _ _ _ Well Latitude: Well Longitude: Flood Plain Designation: Well Elevation: Applicant Name: Applicant Title: Applicant Address: a City: Applicant Phone: _ Applicant email: Property Owner Name: Property Owner Address: City: Property Owner Phone: Property Owner email: 7of OSED WELL INFORMATION Well Total Depth(ft): Acres to be Served Well: Domestic Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Depth of Corcoran Clay(ft): Proposed Well Capacity(gal/ft): — s Estimated Pumping Rate(gal/min): Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): a Estimated Cumulative Extraction Volume before January 1, 2020(acre-feet): Q.y� EXISTING WELLS INFORMATION Total Number of Existing Wells on Property: (c, Please complete the information below for every well on property. Use extra paper if needed Well#1 Information Use of Well: ❑ Domestic El Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ID Industrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter(in): i( ❑ Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Performed: Test Result: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com