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I u;N <br /> SQNJQQQQIN Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> OUNTYGreatness grows 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: 2-75 _ &,;e City: <br /> Well Location APN: 7 _ 210 _ 1)'3 <br /> Well Latitude: If of 6/y-'/ Well Longitude: -7 <br /> Flood Plain Designation: Well Elevation: I`j7 <br /> Applicant Name: ��,'�,S S Applicant Title: <br /> Applicant Address: f70 C 17 City: j���C <br /> Applicant Phone: 3 J!�/- L/7,AT Applicant email: <br /> Property Owner Name: C - 6c,el�� Ci Gt s /(_ <br /> Property Owner Address: , c, 6- City: <br /> Property Owner Phone: 3 7 6 Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): I Acres to be Served by Well: <br /> Use of Well: ❑ Domestic :ZIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): f� <br /> Proposed Well Capacity(gal/ft): t� c,?:_ Estimated Pumping Rate(gal/min): v2zx.? <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): 1- 76: <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): ) l,' <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 ..K 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: ❑ 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 />