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SAK JUAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness 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 <br /> known. The Environmental Health Department must collect this information before a new well <br /> permit is issued and must post the information on the Department's website for public information, <br /> r+ <br /> i <br /> Well Location Address: 13F 9 It I City: <br /> Well Location APN: 7j . - <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> Applicant Name: Applicant Title; <br /> Applicant Address: City: <br /> Applicant Phone: I Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> Well Total Depth(ft): Acres to be Served by Well <br /> Use of Well: <br /> C1 Doff Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> D Other. <br /> Depth of Corcoran Clay{ft): <br /> Proposed Well Capacity(gan): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gallday): ,,Estimated Annual Extraction Volume(acre-feet): <br /> stimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> 14-!�� <br /> • .� rte^y:: <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 /> ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial Cl Stock <br /> Use of Well: <br /> o 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: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/minlft): <br /> Other Pumping Tests Performed: Test Result: <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 4 T 209 468-3420 1 F 209 464-0138 i www.sicehd.com <br />