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SAN 10AQUIN Environmental Health Department <br /> Z46, --COUNTY <br /> Greatness groves 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: City: <br /> Well Location APN: _:5co-0(0 <br /> Well Latitude: 3 3 1 Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: LSC.�IA�IC � LIIL'A%plicant Title: <br /> Applicant Address: ( City: tCA <br /> Applicant Phone: ( c� ) _ 2� Applicant email: LL Q <br /> wt�.�'I�Cv�n-► <br /> Property Owner Name: P�A <br /> Property Owner Address: t7 I� t„ City: (4 C� C( 2 3 <br /> Property Owner Phone: 7YA Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): I Acres to be Served by Well: >< 5;/0 L <br /> Use of Well: ❑Domestic gIrrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): YO Estimated Pumping Rate(gal/min): 17C)o <br /> Anticipated Pumping Schedule(gal/day): 1;216W Estimated Annual Extraction Volume(acre-feet): S' <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): y <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: 0 omestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): l To: From: <br /> Casing Diameter(in): /2 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: I 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 />