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'roum-SAN.DJOAQUIN 'W'hi:�. ` —COUNTY 'SI Greatness grows here. Environmental Health Department New Well Information Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit the following required information, to the extent that can be reasonably known. The Environmental Health Department must collect this information before a new well permit is issued and must post the information on the Department's website for public information. WELLWPATIOI�:ANa Well Total Depth (ft): ' Acres to be Served by Well: Well Location Address: City: aL �� Well Location APN: — Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Other: Proposed Well Capacity (gal/ft): Well Latitude: Well Longitude: — Li - Flood Plain Designation: Well Elevation: L' ' Pumping Rate (gpm): Q To: From: Annual Extraction Volume (acre-feet: Applicant Name: Applicant Title: Applicant Address: �J , City: C �, Applicant Phone: Applicant email: Test Result: Property Owner Name: Property Owner Address: City: Property Owner Phone: Prcperty Owner email: PROPOSED. WELCINFORM .TI©No Y.... Well Total Depth (ft): ' Acres to be Served by Well: Use of Well: ❑ Domestic 1Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Other: Proposed Well Capacity (gal/ft): Total Depth (ft): Estimated Pumping Rate (gal/min): Anticipated Pumping Schedule (gal/day): From: Estimated Annual Extraction Volume (acre-feet): To: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): rrlHwEL 11`ry`ry11Fo ..ss IaN171 i ..n6•Ti., w .� . .11.Y"d�.'.. A1�i�- lx. .lsiJK�ii[M. J.:i •ii:a Rnpl Ii4._ Total Number of Existing Wells on Property: Please complete the information below for every well on property. Use extra paper if needed Well #1 Information Use of Well: Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Other: ❑ Industrial ❑ Stock Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): Q To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gallmin/ft): Other Pumping Tests Performed: Test Result: 1868 E. Hazelton Avenue I Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com