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��utry <br /> SAN.;J OAO U IN EI"Iv'oPfoY"Ini-entai Health Department <br /> 4y.f1 j C O U i'J T Y <br /> ALN <br /> \J(�'CILr)?SS <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number. ApplIcation Type: <br /> Pr 'e:t Address: 5' `r ,a u -r Project APN: <br /> AppllAnt Name:` m JOYN —S I r Title: Icv <br /> Applicant Address: yy _C'A a5-10 • Ci fzi ; q- — Cl S13 C <br /> licant Phone: 20 Emall:1 yo T IT, rM <br /> Property Owner Name: r JV D E12. }Cit <br /> Pro ert,Oxner Address: W 7 btu -c` 4 g Ci. 2i : i tt- — C ---A 30 <br /> Property Owner Phone: c _ U cr r4,0—T 0—S 1 6, <br /> SERVICES INFORMATION <br /> i <br /> Please provide descri ti <br /> on below: _ <br /> Water Supply: <br /> U(.1, '>'>�t V c� LvA] Su—ace Water(Attach Wafer,Rights Information) <br /> Domestic Wastewater Dis osal: <br /> Process Wastewater Discharge: <br /> Ponds: Ciy�5 ,��y Appfcable'NDR: <br /> Storm Drainage System: <br /> WATER USAGE DATA <br /> Provide for total eater us at fug buildout Number PersohslDa -[--Gallon Total Galbns+Da <br /> Domestic Water Usage by Em io eslCustomers: r, _ <br /> Type of Processfirrigated Lands Total Gallons,+Da <br /> Process Water Usage: A <br /> Process Water Usage: N <br /> Irrigatioi Water Usage: N . <br /> i. Tota]Gallons Per D <br /> PROPOSED WELL LOCATION <br /> Well Location Adaress: S' 7_ D)11 <br /> Well Location APN: <br /> VY'ell Latitude: _ �c �c.L Well Longitude] K <br /> Flood Plain Desi nation: Well Elevation: <br /> PROPOSED WELL INFORMATION _ <br /> WellTotal De th{f):, Acres to be Served by Well: <br /> Use of Well: Domestic ❑ Irrigation ED Small Public Water Supply C Municipal?ubiic Water Supply ❑industrial C Stock <br /> L] <br /> Other. <br /> Depth of Corcoran Cia (ft): <br /> Proposed Well Capacity( al;ft): Estimated Pumping Rate lfmin: <br /> Anticipated Pumping Sdiedule allda ): Estimated Annual Extradion Volume acre-feet <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest Onsite: Offsite: <br /> V,fastewater Treatment System: N Sources of Contamination: <br /> Other Wells: Pond/Uke: <br /> Sewer Lines:! Stream/River: <br /> Animal or Fowl Enclosure:) Navigable Waterway:. <br /> Storm Drainage System:; Potential Recharge Features: <br /> GROUNDWATER INFORMATION'. ` <br /> Depth(ft): Sou_rcelDate of Reference: Groundwater Subbasin: <br /> Curren,Depth to Water. ❑Cosumres Subbasin(2-22,16; <br /> Highest Depth to Water: ❑Eastern San Joaquin Subbasin(5-22.01) <br /> Lowest Depth to Water ❑Tracy Subbasin(5-22.15) <br /> 1868 E. Hazelton Avenje I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 �mw.sicehd.cAm <br /> eyf,? <br />