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SAN J OA Q U I N Environmental Health Department <br /> ------C G U N T Y -- <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number: pplication Type: <br /> Project Address: 10116,0 t4 'f Project APN: <br /> Applicant Name: Title: d' <br /> Applicant Address: ( -j' City/Zip: 4r �l <br /> Applicant Phone: 731 Email_ N( . <br /> Property Owner Name: <br /> Property Owner Address: Cit /Zip: <br /> Property Owner Phone: Email: <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply: <br /> El Surface Water(Attach Water Rights Information) <br /> Domestic Wastewater Disposal: <br /> Process Wastewater Discharge: Ponds:1— —TApplicable WDR: <br /> Storm Drainage System: <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number Persons/Da Gallons/Person/Da Total Gallons/Da <br /> Domestic Water Usage b Employees/Customers: D <br /> I <br /> Type of Process/irrigated Lands Total Gallons/Da <br /> Process Water Usage: <br /> Process Water Usa e: <br /> Irrigation Water Usage, <br /> Total Gallons Per Day: <br /> PROPOSED WELL LOCATION <br /> Well Location Address: I Ci : <br /> Well Location APN: .r <br /> Well Latitude: Well Longitude: <br /> Flood Plain Designation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth (ft):1 Acres to be Served by Well: <br /> Use of Well:� � E)Bomestic frigation Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> `❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity (gal/ft): &2 Estimated Pumping Rate (gal/min): <br /> Anticipated Pumping Schedule al/day: Estimated Annual Extraction Volume(acre-feet): <br /> Estim ted Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest( Onsite: Offs' <br /> Wastewater Treatment System: Z z Sources of Cont nation: <br /> Other Wells: and/Lake: <br /> Sewer Lines: Z Stream/River: <br /> Animal or Fowl Enclosure:11 Aavigable Waterwa : <br /> _ Storm Draina e System: PoKntial Recharge Features: <br /> GROUNDWATER INFORMATION <br /> Depth(ftQ Source/Date of Reference: Groundwater Subbasin: <br /> Curre Depth to Water: I�po Y" 'f(2 . � �j ❑ Cosumnes Subbasin(2-22.16) <br /> Highest Depth to Water:� 4k %I 1 t ❑Eastern San Joaquin Subbasin(5-22.01) <br /> Lowest Depth to Water: 'Lk << Ilk ❑ Tracy Subbasin(5-22.15) <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com <br /> 1 of 2 <br />