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' PauU• <br /> S KJ O A Q U I N Environmental Health Department <br /> " lL"'. Wiz:: COUNTY <br /> a 1_I:e0tr,i:55 Cru:vs n: <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: 7-0 1 City: M 99;,7,0(P <br /> Well Location APN: — Q - -mo I <br /> Well Latitude: Well Longitude: — 2- . <br /> Flood Plain Designation: Well Elevation: , <br /> Applicant Name: M �Zarlvs I Applicant Title: J <br /> Applicant Address: Z Quvolki I City: <br /> Applicant Phone: 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): I M U Acres to be Served by Well: <br /> Use of Well: ❑Domestic krigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other. <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(galtft): Estimated Pumping Rate(gaUmin): <br /> Anticipated Pumping Schedule(gal/day): -Estimated Annual Extraction Volume(acre-feet): w 071- <br /> -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 /> Well#1 Information <br /> Use of Well: omestic ❑ 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/mintft): <br /> Other Pumping Tests Performed: Test Result: <br /> 1868 E. Hazefton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />