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SAN.,JOADUIN Environmental Health Department <br />COUNTY— <br />Greatness grows her, <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 O 04ER INFORMATION <br />Well Location Address: Z , <br />City: <br />Well Location APN: .- 0-70— <br />❑ Domestic Irrigation <br />❑ Other: <br />Well Latitude: <br />Well Longitude: <br />Use of Well: <br />Flood Plain Designation: <br />Well Elevation: <br />Estimated Pumping Rate (gallmin): <br />Anticipated Pumping Schedule (gaVday): <br />Applicant Name: <br />Applicant Title: p N N -G, <br />Applicant Address: Q p {G t/ <br />City: MojwivoqJ� if <br />Applicant Phone: <br />Applicant email: <br />Pumping Rate (gpm): <br />To: <br />Property Owner Name: ZN <br />Annual Extraction Volume (acre-feetl <br />Property Owner Address: <br />City: <br />Property Owner Phone: <br />Property Owner email: <br />PROPOSED WELL INFORMATION <br />Well Total Depth (ft):1 I I 10 <br />01 Acres to be Served by Well: . <br />Use of Well: <br />❑ Domestic Irrigation <br />❑ Other: <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Depth of Corcoran Clay (ft): <br />Use of Well: <br />Proposed Well Capacity (gal]ft): <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply <br />Estimated Pumping Rate (gallmin): <br />Anticipated Pumping Schedule (gaVday): <br />Estimated Annual Extraction Volume (acre-feet): <br />To: <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: <br />❑ DomesticT"atiori <br />❑ Other: <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply <br />❑ Industrial ❑ Stock <br />Total Depth (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: <br />From: <br />Casing Diameter (in): <br />To: <br />From: <br />Pumping Rate (gpm): <br />To: <br />From: <br />Annual Extraction Volume (acre-feetl <br />❑ Estimated ❑ Measured <br />Specific Capacity (gallmintft): <br />Other Pumping Tests Performed: <br />Test Result: <br />1868 E. Hazelton Avenue J Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />