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SAN�JOAQUIN %: COUNTY — \,`-'<%„' Greatness grows hers 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. WELL LOCATION AND OWNER INFORMATION Well Location Address: N. MaWNUMCity Acres to be Served by Well: Use of Well: Well Location APN: OVA- _ ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Well Latitude: Well Longitude: Proposed Well Capacity (gal/ft): Flood Plain Designation: Well Elevation: Anticipated Pumping Schedule (gaVday): Pumping Rate (gpm): Estimated Annual Extraction Volume (acne -feet): Applicant Name: Applicant Title. Applicant Address: xAV77 Specific Capacity (gal/minfft): Applicant Phone: I Applicant email: Other Pumping Tests Performed: I Test Result Property Owner Name: Property Owner Address: City: Property Owner Phone: Property Owner email: PROPOSED WELL, INFORMATION Well Total Depth (ft):1 I Acres to be Served by Well: Use of Well: ❑ Domestic 11nigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): Total Depth (ft): Proposed Well Capacity (gal/ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Estimated Pumping Rate (gaVmin): Anticipated Pumping Schedule (gaVday): Pumping Rate (gpm): Estimated Annual Extraction Volume (acne -feet): Annual Extraction Volume (acre-feet Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): EWTINS3 w1 �M ►T10N 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: mestic ❑ Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): r' Pumping Rate (gpm): Annual Extraction Volume (acre-feet Q stimated ❑ Measured Specific Capacity (gal/minfft): Other Pumping Tests Performed: I Test Result 1868 E. Hazelton Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com