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I <br /> SAN J O A Q U I N Environmental Health Department <br /> CC) Ur � I I `r <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number: Application Type : <br /> Project Address : Project APN : <br /> Applicant Name: Title: <br /> Applicant Address : City/Zip : <br /> Applicant Phone : Email : <br /> Property Owner Name: <br /> Property Owner Address : I Cit /Zi <br /> Property Owner Phone: Email : <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply: ❑ Surface Water (Attach Water Rights Information) <br /> Domestic Wastewater Disposal : <br /> Process Wastewater Discharge: Ponds : Applicable WDR: <br /> Storm Drainage System , <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number PersonslDa Gallons/Person/Da Total Gallons/Da <br /> Domestic Water Usage by Employees/Customers : <br /> Type of Process/Irrigated Lands Total Gallons/Da <br /> Process Water Usage : <br /> Process Water Usage: <br /> Irrigation Water Usage : <br /> Total Gallons Per Day: <br /> PROPOSED WELL LOCATION <br /> Well Location Address: I Cit <br /> Well Location APN : <br /> Well Latitude : Well Longitude : <br /> Flood Plain Designation : Well Elevation : <br /> PROPOSED WELL INFORMATION <br /> Well Total De th ft : Acres to be Served b Well : <br /> Use of Well : ❑ Domestic ❑ 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): Estimated Pumping Rate al/min : <br /> Anticipated Pumping Schedule (gal/day): Estimated Annual Extraction 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 (ft) : Onsite: Offsite : <br /> Wastewater Treatment System : Sources of Contamination : <br /> Other Wells : Pond/Lake : <br /> Sewer Lines : Stream/River: <br /> Animal or Fowl Enclosure: Navigable Waterway: <br /> Storm Drainage System : 1 I System: Potential Recharge Features : <br /> GROUNDWATER INFORMATION <br /> Depth (ft): Source/Date of Reference : Groundwater Subbasin : <br /> Current Depth to Water: ❑ Cosumnes 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 Avenue Stockton , California 95205 T 209 468 -3420 F 209 464- 0138 www . sicehd . com <br /> 1 of 2 <br />