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SKJOAHIN COUNTY cqk� 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 Address: City: q Well Location APN:_AA 1—a — Ia Acres to be Served by Well: Well Latitude: O ?j Well Longitude: —111. , (� c6?� Flood Plain Designation: I Well Elevation: Proposed Well Capacity (gaVft): ❑ Open Bottom or Screen Interval (ft): Estimated Pumping Rate (gal/min): Applicant Name: Applicant Title: N Applicant Address: city: 1 Z Applicant Phone: I Cj Applicant email: From: Annual Extraction Volume (acre-feet Property Owner Name: Estimated ❑ Measured Property Owner Address: City Specific Capacity (gaUmWft): Property Owner Phone,/Property Owner email: Y: Well Total Depth (ft):1 I Acres to be Served by Well: Use of Well: ❑ Domestic ❑ Irrigation ❑ Other. ❑ Small Public Water Supply ❑ Munico Public Wafter Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): ❑ Industrial ❑ Stock Proposed Well Capacity (gaVft): ❑ Open Bottom or Screen Interval (ft): Estimated Pumping Rate (gal/min): Anticipated Pumping Schedule (gal/day): Casing Diameter (n): Estimated Annual Extraction Volume (akxe-feet): From: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): ll j. 7a.. f . f a� ..5-. �.�•r.-` Total Number of Existing Wells on Property: Please complete the information below for every well on property. Use extra paper if needed Well iM Information Use of Well: mestic ❑ Irrigation ❑ Small Public Water Supply ❑ Munidpal Public Water Supply ❑ Other. ❑ Industrial ❑ Stock Total Depth (ft): ko 0 ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (n): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet Estimated ❑ Measured Specific Capacity (gaUmWft): Other Pumping Tests Performed: I Test Result 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjoehd.com