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S A N J O A Q U l N Environmental Health Department <br /> _ 7- <br /> Water Usage Information <br /> _ PROJECT INFORMATION _ <br /> Application Number. Application Type: <br /> Project Address: Z Project APN: <br /> Applicant Name: Title: <br /> Applicant Address:/ L /✓�d5 Cit/Zp: <br /> Applicant Phone: . Q Email: <br /> Property Owner Name: h <br /> Property Owner Address: / Z 5 F ✓� ,F4'1>' /moi✓• C_it 1Zi : Gz:'1r: , ^✓ Z�'` <br /> PropeMy Owner Phone: <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: P nds: A �/� � ,� Ap licable WDR: 5''— 2'P,O- Fi4 <br /> Storm Drainage System: 1IVC G' - vb Z 17 <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number Persons/Da Gal Ions/Person/D ay Total GallonslDa <br /> Domestic Water Usage by Employees/Customers: 46 v <br /> Type of Processilrri aced LandsTotal Gallons/Da <br /> Process Water Usage: <br /> Process Water Usage: <br /> lni ation Water Usage: l7Na <br /> Total Gallons Per <br /> PROPOSED WELL LOCATION <br /> Well Location Address: I City: <br /> Well Location APN: <br /> _ Well Latitude: " Well Longitude: _ _ <br /> Flood Plain Designation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth h): Acres to be Served by Well: <br /> Use of Well: ❑Domestic ❑Irrigation ❑SmalPublic Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: I I ) 1A <br /> Depth of Corcoran Clay ft <br /> Proposed Well Ca acil gal/ft: Estimated PumpingRate aUmin: <br /> Anticipated Pumping Schedule gal/da : Estimated Annual Extraction Volume acre feet <br /> Estimated Cumulative Extraction Volume before January 1,202�acre <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: i Pond/Lake: <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): Sourcef0ate of Reference: Groundwater Subbasin: <br /> Current Depth to Water: ❑Cosumnes Subbasin(2-22,16) <br /> Highest Depth to Water: 1 ❑Eastern San Joaquin Subbasin(5.22.01) <br /> Lowest Depth to Water: ❑Tracy Subbasin(5-22.15) <br /> 1868 E.Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 sic�fid.com <br /> 1 of 2 <br />