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g*-"AN [+� ! <br /> AQI Environmental Health Department <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:_15(3(-5, r 5c e'l C it Be IC ! c <br /> - - -- <br /> Well Location AIN: - <br /> _Well --- <br /> Latitude: 1 Well Longitude:! <br /> Flood Plain Designation: Well Elevation: - <br /> AppGcaMName: �rApplicant Tide: arch ti <br /> Applicant Address: 4 City: <br /> Applicant Phone: <br /> I Z09 3 5 1-G i'�i Applicant email: <br /> � Property Owner Name:-T- <br /> Property ONmerAddress:i 9Z� nu;i <br /> � _ f._ City: 5Lgi <br /> �-- <br /> Property Own r Phone:( 2�9_ �'_ 6 Property Owner email: <br /> ----- ----------------- <br /> PROPOSED WELL INFORMATION <br /> Wer.Total Depth(ft): (p Acres to be Served by Well: <br /> Use of Well: <br /> ❑Domestic lffi Irrigation 0 Small Public Water Supply ❑Municipal Public Water Supply 0 Industrial ❑Stock <br /> ❑Other: <br /> — Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): /GO i Estimated Pumping Rate(gaVmin):! <br /> Anticipated Pumping Schedule(gal/day): _'Y")rt Estimated Annual Extraction Volume(acre-feet):! <br /> - - Estimated Cumulative Extraction Volume before January 1,2020(acre-feet):! — <br /> EXISTINGWELLS INFORMATION .___ <br /> Total Number of Existing Wells on Property: Z <br /> Please complete the information below for every well on property.Use extra paper if needed <br /> Welt#1 Information _`""- <br /> Use of Well: 0 Domestic K Irrigation 0 Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial H9 Stock <br /> G Other. <br /> Total Depth(ft): q _ <br /> To: From: <br /> Casing Diameter(in): IL( 9 Open Bottom or Screen Interval(ft):To From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: 13 jj >ff,Estimated ❑ Measured <br /> _Specific Capacity(gaL�minlft): .`f 2,i <br /> - _L--____ -. <br /> Other Pumping Tests Perforrried:: Test Result <br /> 1868 E. Hazelton Avenue I Stockton, Caiifomia 95205 I T 209 468-3420 1 F 209 454-0138 1 L,nv+,v.sjcehd.corn <br />