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SAKJOAQUIN COUNTY 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. WELL LOCATION AND OWNER INFORMATION Well Location Address:, I' '-Ti, City: a d Well Location APN: C) �S'_ 2 _ c:;?O,,2 ❑ Domestic P.Irrigation ❑ Other: Well Latitude: r9� -o Well Longitude: Proposed Well Capacity (gal/ft): Flood Plain Designation: Estimated Pumping Rate (gal/min): Well Elevation: Anticipated Pumping Schedule (gal/day): From: Applicant Name: io S1 Applicant Title: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): Applicant Address: t7P City: w,�Jv&1i Applicant Phone: v 9._ _ 47.: 71� Applicant email: ❑ Estimated ❑ Measured Property Owner Name: Specific Capacity (gal/min/ft): Property Owner Address: City: Property Owner Phone: Property Owner email: PROPOSED WELL INFORMATION Well Total Depth (ft): Total Number of Existing Wells on Property: Please complete the information below for every well on property. Use extra paper if needed SC; Acres to be Served by Well: Well #1 Information Use of Well: ❑ Domestic P.Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Proposed Well Capacity (gal/ft): Estimated Pumping Rate (gal/min): ❑ Open Bottom or Screen Interval (ft): Anticipated Pumping Schedule (gal/day): From: Estimated Annual Extraction Volume (acre-feet): To: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): Pumping Rate (gpm): EXISTING WELLS INFORMATION 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 ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com