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' _ SAN J O A Q U I N Environmental Health Department <br /> —COUNTY---- <br /> 111 L. Greotrness 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 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: T 1 City: <br /> Well Location APN:; <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation:) Well Elevation: <br /> Applicant Name: P�� ApplicantTitle: <br /> Applicant Address: City: 44 <br /> Applicant Phone: Applicant email: �? <br /> Property Owner Name: Cie i <br /> Property Owner Address: ^ City: <br /> Property Owner Phone: Property Owner email: I j <br /> -PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): � ' Acres to be Served by Well: <br /> Use of Well: <br /> Domestic Irrigation ❑ Small Public Water Supply [I Municipal Public Water Supply Industrial ❑ Stock <br /> Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gallft): Estimated Pumping Rate(gaVmin): <br /> Anticipated Pumping Schedule(gal/day):1 Estimated Annual Extraction Volume(acre-feet): <br /> Estimated Cumulative Extraction Volume before January 1, 2020(acre-feet):I <br /> EXISTING WELLS INFORMATION II <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 n Irrigation ❑ Small Public Water Supply 7, Municipal Public Water Supply ::1 Industrial ❑ Stock <br /> ❑ Other: _____ _ <br /> Total Depth(ft): 4,V4 , ,— To: From: <br /> Casing Diameter(in):j & ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm):i /0 To: From: <br /> Annual Extraction Volume(acre-feet: a ❑ Estimated u Measured <br /> Specific Capacity(gal/min/ft):., _ <br /> Other Pumping Tests Performed: enc_ Test Result-1 <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 viww.sjcehd.com <br />