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DocuStgn Envelope ID: C620F69E-ECD2-4050-BB49-C4AB63D3Ei 19 <br />SAN 10AQUIN <br />..__._.COU N T Y ............... <br />Greatness grows here. <br />Environmental Health Department <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 known. <br />The Environmental Health Department must collect this information before a new well permit is <br />issued and must post the information on the Department's website for public information. <br />WELL LOCATION AND OWNER INFORMATION <br />A a oA <br />Well Location Address. --f <br />- -7 -' <br />VVV #D <br />�� City:b <br />Well Location APN: <br />❑ Domestic '$ Irrigation <br />❑ Other: <br />Well Latitude. .moi1407Well <br />Longitude: <br />�— (a' <br />Flood Plain Designation: <br />Well Elevation: <br />O� <br />Anticipated Pumping Schedule (gal/day): <br />Pumping Rate (gpm): <br />Applicant Name: (4 <br />r{1 It <br />t IfIly Applicant Title: If l <br />Applicant Address: D arc ( <br />City: t 644'tI66- <br />Applicant Phone: 9,01\(( <br />Applicant email: <br />Other Pumping Tests Performed:1 <br />I Test Result: <br />Property Owner Name: A mot K1 <br />Property Owner Address:City: <br />Property Owner Phone: 3 — <br />Property Owner email: <br />PROPOSED WELL INFORMATION <br />Well Total Depth (ft): <br />Acres to be Served by Well: <br />Use of Well: <br />❑ Domestic '$ Irrigation <br />❑ Other: <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />Depth of Corcoran Clay (ft). <br />Total Depth (ft): <br />Proposed Well Capacity (gal/ft): <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: <br />Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): <br />EXISTING WELLSINFORMATION <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 ?Q, 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: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed:1 <br />I 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 />