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SAN J O A Q U I N Environmental Health Department <br /> —COUNTY— <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: t c� L- k R City: <br /> Well Location APN: 2-3 9 Z I �; <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Z� �� Applicant Title: <br /> Applicant Address: 3�' L ,r�s L City: M d?5- <br /> {" <br /> Applicant Phone: 3 YQ i I Applicant email I.y cr 2-C,1 J ;d �.� <br /> Property Owner Name: <br /> Property Owner Address: <br /> Property Owner Phone: 2—o 3 R Property Owner email: 14'1 <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): 1 -7 S p Acres to be Served by Well: L 1 b <br /> Use of Well: <br /> ❑ Domestic Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran dlay(ft): <br /> Proposed Well Capacity(gal/ft): j Estimated Pumping Rate(gal/min): Z0 v L <br /> Anticipated Pumping Schedule(gal/day): 'Estimated Annual Extraction Volume(acre-feet): <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: ❑ Domestic Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> 9-Other'.. c� <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:1 Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />