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SANiJOAQUIN V. L% 6- `: —COUNTY— Greatness COUNTY— Greatness qrows here. Environmental Health Department New Well Information Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit the following required information, to the extent that can be reasonably known. The Environmental Health Department must collect this information before a new well permit is issued and must post the information on the Department's website for public information. PROPOSED WELL NFQM,.TiON Well Total Depth (ft):j I U0 Well Location Address: Use of Well: I City: Well Location APN:'L _[M 02D Depth of Corcoran Clay (ft): Total Depth (ft): To: Casing Diameter (in): ❑ Open Bottom or Screen Interval (ft): To: Pumping Rate (gpm): To: Well Latitude: Annual Extraction Volume (acre-feet:/_Estimated ❑ Measured Well Longitude: — 2. • 2 Flood Plain Designation: Estimated Annual Extraction Volume (acre-feet): Well Elevation: 3 i Applicant Name: Applicant Title: Applicant Address: - city: G Applicant Phone: -4 a Applicant email: Property Owner Name: Property Owner Address: City: Property Owner Phone: Property Owner email: PROPOSED WELL NFQM,.TiON Well Total Depth (ft):j I U0 Acres to be Served by Well: 11(J . Use of Well: ❑ Domestic )(Irrigation ❑ Other. ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): Total Depth (ft): To: Casing Diameter (in): ❑ Open Bottom or Screen Interval (ft): To: Pumping Rate (gpm): To: Proposed Well Capacity (gaVft): Annual Extraction Volume (acre-feet:/_Estimated ❑ Measured Estimated Pumping Rate (gal1min): Anticipated Pumping Schedule (gal/day): Estimated Annual Extraction Volume (acre-feet): Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): ERStItVfiELESr1FQRT[Q Total Number of Existing Wells on Property: Please complete the information below for every well on property. Use extra paper if needed Well #1 Information Use of Well:Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Other: C3 Industrial C1 Stock Total Depth (ft): To: Casing Diameter (in): ❑ Open Bottom or Screen Interval (ft): To: Pumping Rate (gpm): To: From: From: From: Annual Extraction Volume (acre-feet:/_Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result 1868 E. Hazetton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com