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SANAOAQUIN Environmental Health Department <br /> r� —COUNTY <br /> 9� P Greatness grows here. <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 <br /> known. The Environmental Health Department must collect this information before a new well <br /> permit is issued and must post the information on the Department's website for public information. <br /> WELL L.OCATION`AND;OWNEI�"INFORIylA1,ION'-` <br /> Well Location Address: N City: <br /> Well Location APN: <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Applicant Title: `J�j W <br /> Applicant Address: 1 , City: Z <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED WELl:INFORMAT1l0N' <br /> Well Total Depth(ft):1 I Acres to be Served by Well: <br /> Use of Well: ❑Domestic VIrrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other. <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): Lal <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXlST[NG;.Vk� L 1�f RT k �n �+a:Y as w <br /> •rias..' s- ,a <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 /> ❑Other. <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(gat/min/ft): <br /> Other Pumping Tests Performed: 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 />