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°pf SKJOAQUIN <br />COUNTY <br />Grectness cgrov,s her, <br />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: ,. <br />City:1 La <br />Well Location APN: 00 S- D w - � (, <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrialock <br />❑ Other: <br />Well Latitude: 00 3 y. /_T <br />Well Longitude: <br />— / � <br />Flood Plain Designation: /i% <br />Well Elevation: <br />J fl <br />Casing Diameter (in): <br />Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): <br />Applicant Name: 4A 61105f y/A& <br />Applicant Title: <br />Applicant Address: • o /lo ���, <br />City: <br />Applicant Phone: _ <br />Applicant email: <br />❑ Estimated ❑ Measured <br />Property Owner Name: S )"YL <br />Property Owner Address: Sa,_„e <br />City: <br />Other Pumping Tests Performed: <br />Property Owner Phone: y P _ -z <br />Property Owner email: <br />PROPOSED WELL INFORMATION <br />Well Total Depth (ft): -7c? <br />1- Acres to be Served by Well: <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrialock <br />❑ Other: <br />Depth of Corcoran Clay (ft): <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Proposed Well Capacity (gal/ft): <br />Estimated Pumping Rate (gal/min): i <br />Anticipated Pumping Schedule (gal/day): <br />Estimated Annual Extraction Volume (acre-feet): <br />Casing Diameter (in): <br />Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): <br />EXISTING WELLS INFORMATION <br />Total Number of Existing Wells on Property: �v <br />Please complete the information below for every well on property. Use extra paper if needed <br />Well #1 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation <br />❑ Other: <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Total Depth (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />To: From: <br />Pumping Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: <br />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 />