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1puiN C, <br /> °`i` SAN-IOAQUIN Environmental Health Department <br /> '�' —COUNTY <br /> — <br /> IF Greatness 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: 1,73 , v City: ,,vk <br /> Well Location APN: 003—/C>0 —7 <br /> Well Latitude: , 0 3 72 3 a Well Longitude: ' <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: S n . , Applicant Title: <br /> Applicant Address: ,B City: <br /> Applicant Phone: _ l f' J Applicant email: Wel0 1kgn,E <br /> Property Owner Name: en <br /> Property Owner Address: 14g ` -J r City: 07-1t <br /> Property Owner Phone: /—f ?q—j6Lq _ Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft):1 I Acres to be Served by Well: <br /> Use of Well: ❑ 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): (- rn Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal/day): I Estimated Annual Extraction Volume(acre-feet): <br /> 0� Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): C> <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />