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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <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:, nbo (AMP V4 1 'NN City: <br /> Well Location APN: 2 10- lrl ? <br /> Well Latitude: '�j f V C' Well Longitude:r <br /> Flood Plain Designation: Well Elevation:I ACj <br /> Applicant Name: Applicant Title: N <br /> Applicant Address: l. �x ( City: L1 <br /> Applicant Phone: 1 . ' Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft):1 I W Acres to be Served by Well: <br /> Use of Well: <br /> ❑ Domestic Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gallft): Estimated Pumping Rate(gallmin): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): <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 /> 1 I l <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: li Estimated ❑ Measured <br /> Specific Capacity(gal/minlft): <br /> Other Pumping Tests Performed: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 />