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SAN JOAQUIN Environmental Health Department <br /> r� - <br /> ---COUNTY <br /> ---- <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: r ICity: <br /> Well Location APN: ,Z _ 0_ <br /> Well Latitude: 3-1'y3 3 Well Longitude: 12 < <br /> Flood Plain Designation: AlWell Elevation: <br /> Applicant Name: Pot" I Applicant Title: W,n .p . <br /> Applicant Address: �� �F� City: <br /> Applicant Phone: S3L_ (: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: jt, Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): S6 Acres to be Served by Well: <br /> Use of Well: ❑ Domestic 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): 4�0 Estimated Pumping Rate(gal/min): L/GQ <br /> Anticipated Pumping Schedule(gal/day): AA- <br /> Estimated Annual Extraction Volume(acre-feet): <br /> Esti ated Cumulative Extraction Volume before January 1,2020(acre-feet): lj&q2 <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 rrigation ❑ 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(qpm): / to To: From: <br /> Annual Extraction Volume(acre-feet: irSS H"� i4 1� 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 />