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SAN 10AQUIN Environmental Health Department <br /> :. -- C O U N T Y------ <br /> Greotness 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 "?��� l� -, �i City: st ltt'� la <br /> Well Location APN: <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: �h Applicant Title: .W <br /> Applicant Address: City: 1AC',,atE' p <br /> Applicant Phone: 3 Applicant email: (( - 1 .�j,,iL <br /> Property Owner Name: ( „t <br /> Property Owner Address:JlL",4aA,�.�, City: r�C4L <br /> Property Owner Phone: ••,Cf - -1, (4- Property Owner email• `)jk Ca. q- Ccs <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): a Acres to be Served by Well: <br /> Use of Well: ❑ Domestic O Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gal/ft): j,400- j Estimated Pumping Rate(gal/mix.-I(gal/mix.-I363 <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-f et): U-AkW:.1A <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre- et): <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 I&Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): To: From: C�: <br /> Casing Diameter(in): Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: � ztvuf „• ❑ 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.com <br />