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SANPIOAQUINp <br />Environmental Health Department <br />—COUNTY <br />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,LOCQ►TIOND 4WNEiINERyIA ION <br />'°' �' `, ` .y_.., , <br />Well Location Address: 0 <br />N1 City: NdN IqJoly <br />Well Location APN: _ <br />Well Latitude: <br />Well Longitude: — <br />Flood Plain Designation: <br />Well Elevation: <br />Total Depth (ft): <br />Proposed Well Capacity (gaVft): <br />Applicant Name: <br />Applicant Title: J <br />Applicant Address: <br />City: N <br />Applicant Phone:11 TIAApplicant <br />email: <br />Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): <br />❑ Estimated ❑ Measured <br />Property Owner Name: <br />Property Owner Address: <br />City: <br />Test Result: <br />Property Owner Phone: <br />Property Owner email: <br />PROPOSED.WELL IMFORM�►T[ON `, <br />'°' �' `, ` .y_.., , <br />Well Total Depth (ft): <br />Acres to be Served by Well: <br />Use of Well: <br />❑ Domestic 1 Irrigation <br />❑ Other: / <br />❑ Small Public Water Supply EI Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Depth of Corcoran Clay (ft): <br />Total Depth (ft): <br />Proposed Well Capacity (gaVft): <br />To: From: <br />❑ Open Bottom or Screen Interval (ft): To: From: <br />To: From: <br />Estimated Pumping Rate (gal/min): <br />Anticipated Pumping Schedule (gal/day): <br />Pumping Rate (gpm): <br />Estimated Annual Extraction Volume (acre-feet): <br />Annual Extraction Volume (acre -feet -1 <br />Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): <br />l?� NO WEt:_ sS a ttort <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: <br />❑ Domestic ❑ Irrigation <br />❑ Other. <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Total Depth (ft): <br />To: From: <br />❑ Open Bottom or Screen Interval (ft): To: From: <br />To: From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre -feet -1 <br />❑ Estimated ❑ Measured <br />Specific Capacity (gaVmin/ft): <br />Other Pumping Tests Performed: <br />Test Result: <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />