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SAN JOAQUIN <br />x COUNTY <br />� ; r Greatness grows here. <br />Environmental Health Department <br />Water Usage Information <br />I Total Gallons Per Day: <br />PROJECT INFORMATION <br />Well Location Address: <br />Well Location APN: r <br />I Ci : <br />i <br />Application Number: <br />Well Longitude: <br />pplication Type: <br />Flood Plain Designation: <br />Project Address: 10116,0 T <br />Project APN. o <br />© Zj2.. 3j <br />Applicant Name: <br />Acres to be Served by Well: <br />Use of Well: <br />Title: d' <br />Depth of Corcoran Clay (ft): <br />Applicant Address: <br />! <br />-j' <br />City/Zip: <br />Antici ated Pumping Schedule al/da <br />Applicant Phone: <br />Estimated Annual Extraction Volume (acre-feet)] <br />.Email: <br />Esti- ted Cumulative Extraction Volume before January 1, 2020 acre-feet <br />SITING INFORMATION <br />Distance To Nearest (ft): Onsite: <br />Offsite: Distance To Nearest ( Onsite: Offs' <br />Property Owner Name: <br />Sources of Cont nation: <br />Other Wells: <br />and/Lake: <br />-Property Owner Address: <br />Stream/River: <br />Ci /Zip: <br />avi able Waterway: <br />Storm Drainage System:1 System: <br />Propeqy Owner Phone: <br />I Email: <br />Depth (ft): <br />Source/Date of Reference: <br />SERVICES INFORMATION <br />Curre tDepth to Water. <br />tpo <br />Please provide description below: <br />❑ Cosumnes Subbasin (2-22.16) <br />I ❑ Eastern San Joaquin Subbasin (5-22.01) <br />❑ Tracy Subbasin (5-22.15) <br />j Highest Depth to Water: �t l) <br />'~Lowest <br />Water Supply: <br />Depth to Water: <br />❑ Surface Water (Attach Water Rights Information) <br />Domestic Wastewater Disposal: <br />Process Wastewater Discharge: Ponds: <br />A licable WDR: <br />Storm Drainage System: 412 <br />e2VS�� <br />WATER USAGE DATA <br />Provide for total water usage at full buildout <br />Number Persons/Da <br />Gallons/Person/Da <br />Total Gallons/ -Da <br />Domestic Water Usage by Employees/Customers: <br />D <br />T e of Process/Irrigated Lands <br />Gallons/Day <br />Process Water Usage: <br />, <br />Process Water Usage, <br />Irrigation Water Usage: <br />I Total Gallons Per Day: <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />1 of 2 <br />PROPOSED WELL LOCATION <br />Well Location Address: <br />Well Location APN: r <br />I Ci : <br />i <br />Well Latitude: <br />Well Longitude: <br />Flood Plain Designation: <br />Well Elevation: <br />PROPOSED WELL INFORMATION`' <br />Well Total Depth (ft):1 <br />Acres to be Served by Well: <br />Use of Well: <br />mestic �lfrigation ❑ Small Public Water Supply El Municipal Public Water Supply ❑ Industrial E) Stock <br />❑ Other: <br />Depth of Corcoran Clay (ft): <br />Proposed Well Capacity (gal/ft): <br />Estimated Pumping Rate al/min : - <br />Antici ated Pumping Schedule al/da <br />Estimated Annual Extraction Volume (acre-feet)] <br />Esti- ted Cumulative Extraction Volume before January 1, 2020 acre-feet <br />SITING INFORMATION <br />Distance To Nearest (ft): Onsite: <br />Offsite: Distance To Nearest ( Onsite: Offs' <br />Wastewater Treatment System: <br />Sources of Cont nation: <br />Other Wells: <br />and/Lake: <br />Sewer Lines: <br />Stream/River: <br />Animal or Fowl Enclosure: <br />avi able Waterway: <br />Storm Drainage System:1 System: <br />PoKntial Recharge Features: <br />GROUNDWATER INFORMATION <br />Depth (ft): <br />Source/Date of Reference: <br />Groundwater Subbasin: <br />Curre tDepth to Water. <br />tpo <br />❑ Cosumnes Subbasin (2-22.16) <br />I ❑ Eastern San Joaquin Subbasin (5-22.01) <br />❑ Tracy Subbasin (5-22.15) <br />j Highest Depth to Water: �t l) <br />'~Lowest <br />it <br />Depth to Water: <br />,4l << it <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />1 of 2 <br />