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c� SAN 10AQUIN 4;6") COUNTY ``cg4r?rP� Greatness grows he 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 Total Depth Well Location Address: as -7 I;. D y C et r4-!., ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Well Location APN: Well Latitude: Flood Plain Designation: 3`7 0 ? 3 Well Longitude: I -X I, D.,c� -� jo Well Elevation: -7y, Applicant Name: ' rv, o,G Applicant Title: ..i Applicant Address: -3ao S . IC;��o Q City: -ref Applicant Phone: ?-,zj _ b7 — q 3a Applicant email: I w tv.r' t I Test Result: Property Owner Name: K L Property Owner Address:i f 7 olCity: Property Owner Phone: j eS r fS - `i 5 I Property Owner email: ; tv mOL�. PROPOSED WELL INFORMATION Well Total Depth Acres to be Served by Well: , a Use of Well: ❑ Domestic rErfrrjgation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): Total Depth (ft): Proposed Well Capacity (gal/ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Estimated Pumping Rate (gal/min): 1p Oo Anticipated Pumping Schedule (gal/day): boa Estimated Annual Extraction Volume (acre-feet): Zk_ ) Annual Extraction Volume (acre-feet: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): 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): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping I Test Result: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com 'm,%; I. C,a I D . (-3-,V