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SANJ0A0UIN Environmental Health Department <br /> COUNTY <br /> 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: -A - City: ;J <br /> Well Location APN: ino- no <br /> Well Latitude: Well Longitude: — (� <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Applicant Title: N <br /> Applicant Address: City: <br /> Applicant Phone: cJ , Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: 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 X Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gaVft): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal/daft Estimated Annual Extraction Volume(acre-feet):jZ6,5 <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INFORMATION <br /> Total Number of Existing Wells on Property: WAV, <br /> Please complete the information below for every well on property. Use extra paper if needed <br /> Well 111 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-feetl ❑ Estimated ❑ Measured <br /> Specific Capacity(gaVmin/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.coni <br />