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SAN 10 AQ U I N Environmental Health Department <br /> O U �! <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 /> Well Location Address:' City: { <br /> Well Location APN: - <br /> Well Latitude:' Well Longitude: — <br /> Flood <br /> ongitude: —Flood Plain Designation: Well Elevation: <br /> Applicant Name: - Applicant Title: <br /> Applicant Address: 2 City: <br /> Applicant Phone: ' Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: i City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth ft Acres to be Served by Well: <br /> El Domestic Irrigation EllSmallPublic Water Supply P_ Municipal Public Water Supply El Industrial [I Stock <br /> =Useof <br /> E Other: <br /> Depth of Corcoran Clay(ft): t <br /> Proposed Well Capacity(galfft): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal1day)d Estimated Annual Extraction Volume(acre-feet): AL <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INFORMATION _ <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 0 Small Public Water Supply 7— 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: (� f Estimated ❑ Measured <br /> Specific Capacity(gal/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.conn <br />