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. r <br /> SAN J O A Q U ! N Environmental Health Department <br /> C0 TY <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: / / �� ` j City: A <br /> Well Location APN: <br /> Well Latitude: Well Lc,lgitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Applicant Title: <br /> Applicant Address: , City: ,; <br /> Applicant Phone: 7 - Applicant email: lj�y jl j' <br /> Property Owner Nam(r, ,; <br /> Property Owner Address: " 5c a C City: <br /> Property Owner Phone: f Proparty Owner email: <br /> PRCPOS'-:D WELL INFORMATION _ <br /> Well Total Depth(ft):1 I Acres to,be Served by Well: <br /> Use of Well: <br /> X 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): j.4,7 Estimated Pumping Pate(gal/min): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): <br /> L 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 /> Weli#1 Information <br /> Use of Well: <br /> ❑ 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 Vo!ume(acre-feet: ❑ Fstim_ated ❑ 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.sicehd.com <br />