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�"'''=�'�"`� SAN�,IQAQUIN Environmental Health Department <br /> �.&.�?� .,��.�"�' —COUNTY <br /> '��iZlf�a�� Greotn ess gr ws here, <br /> Water Usage Information <br /> �- -- � - ° ` P DJEDTtdN_O. i4TlON -' <br /> lication Number: lication T e: - <br /> Pro act Address: -1 Pro'ect APN: <br /> licant Name: M t Title: �- o W <br /> Iican[Address- -C. QY30 Ci 2i - 9 O <br /> licent Phone: 20 Email' t.n <br /> Pro a Owner Name: r 6!L- <br /> Pro Owner Address' W ?= 4 C' 2i t - C o <br /> Pro Owner Phone: a - a o Email: rh az !ra•.P <br /> c — � ;SERVIGES:7NFd?MAT{ON `..-. '::"='i. . � •15,,.:.: _ <br /> Please rovitle descri tion below: ,�tt� �� ��,,,,nn�� <br /> Water Supply: OW r V eA-t.G iN�i^^�61 Surtace Water(Attach Water Rights/nformatlon) <br /> Domestic Wastewater Dis osal: <br /> Process Wastewater Dische e: Pontls: Ovt S Iicabie WOR: <br /> Storm Draina e S stem: <br /> .. - ,. :�If ER:J]SAGE BATA <br /> ` Provide for rota/water use eat fu//bu/ldout NumDet Persons/Da' Gallons/Person/Da Total Ga7loris/Da <br /> Domestic Water Usa e b Em Ie ees/Customers: e�. - <br /> . T e of Prbcess/Ird-atetl iantls: 'Total a I a-' <br /> Process Water Usa e: r� <br /> Process Water Usa e: w <br /> Ini anon Water Usa e: N. <br /> '.;.' Tota4Ctlallotis FeF��D""'::I <br /> .RQ ..OSiHO WF1'L'lOGAT10N � .�. _:. .... __ '. <br /> Well Location Address: W .• Ci o <br /> Wall Location APN: <br /> Well Latitutle: Well Lon nude: <br /> Flootl Plain Desi nation: Well Elevation: <br /> .:. . . _. PRO�O$(E�'Y.YV11Z.. -..tndq .. :� <br /> Well Total De th ft: Aaea to be Sarvetl b Well: <br /> Use of Well: �Domestic �Irrigation O Small Public Water Supply �Muniapal Public Water Supply O Intlustdal O Stock <br /> �Other. <br /> De th of Corcoran Cla ft <br /> Pro d Wali Ca aci a1Ht: Estimatetl Pum In Rate al/min <br /> Antici atetl Pum i Schedule al/tla Estlmated Annual Extraction Volume acre-fee[ <br /> Estimatetl Cumulative Extmetlon Volume before Janua 7,2020 acre-feet <br /> sJ,T.1NG7NP„OhiNlli.7iON :. r- _ - . ,.. <br /> Dlstanee To Nearest ft: Onsite: Offsite: Distance To Nearest ft: Onsite: Offsite: <br /> Wastewater Treatment S stem: N Sources of Contamination: <br /> Other Wells: Pond/Lake: <br /> Sower Lines: Stream/River: <br /> Animal or Fowl Enclosure: Nevi able Waterwa <br /> Storm Draina e S stem: Potential Rechar a Features: <br /> .. "`GROUND ATERJNFORMA :. _. - - �_ - -- '_' <br /> De th ft: Source pate of Reference: Groundwater Subbasin: <br /> Curren[Depth to Water: O Cosumnes Subbasin(2-22.78) <br /> Highest Depth to Water: o Eastern San Joaquin Subbasin(5-22.07) <br /> Lowest Depth b Water: �Tm Subbasin(5-22.75) <br /> 7868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0738 I www.sicahtl.com <br /> 1M0 <br />