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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Water Usage Information NSA <br /> PROJECT INFORMATION <br /> Application Number: Application Type: <br /> Project Address: Project APN: <br /> Applicant Name: Title: <br /> Applicant Address: Cit /Zip: <br /> Applicant Phone: Email: <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: ❑ 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 Persons/Da 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: City: <br /> Well Location APN: <br /> Well Latitude: Well Lon itude: <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 El Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial El 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:j 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br /> 1 of 2 <br />