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S A N_ J O A Q U I N Environmental Health Department <br /> - <br /> --COU NTY- - <br /> - <br /> Greot!,C >s <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: I ol b$ 5 a+'oleiCity: 's �c <br /> Well Location APN: 2-qc(- I/D. IY <br /> Well Latitude: 1 1 1z, Well Longitude: <br /> Flood Plain Designation: 0 Well Elevation: <br /> Applicant Name: (�I rye uK wJ.t Applicant Title: OW,1_t r <br /> Applicant Address: q ��r City: Frca/#A <br /> Applicant Phone: _(6 lb-1 7, Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: p!w` City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED,WELL INFORMATION <br /> Well Total Depth (ft): Acres to be Served by Well: YO <br /> Use of Well: ❑ Domestic XIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): o Estimated Pumping Rate(gal/min): tj <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet):Les-c <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: ❑ 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 />