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SAN J OAQ U I N Environmental Health Department ........._.C J U N 1-Y.................._. Water Usage Information PROJECT INFORMATION Application Number: Application Type: Project Address: 5225 W 11TH ST TRACY CA 95304 Project APN: 250-110-14 Applicant Name:ABDULLAH AKBARI Title: OWNER Applicant Address: 1753 WOODLAND LANE Cit /ZI . TRACY 95304 Applicant Phone:925-9223455 Email: PATRIOTTOWSERVICE@GMAIL.COM Property Owner Name:BALWINDER KAUR Property Owner Address:5225 W 11TH ST City/Zip: TRACY 95304 Property Owner Phone:209-407-0018 Email: MANJIT5496@GMAIL.COM SERVICES INFORMATION Please provide description below: Water Supply: OWN PRIVATE WELL ONSITE ® Surface Water(Attach Water Rights Information) Domestic Wastewater Disposal: Process Wastewater Discharge: Ponds: ONSITE EXISTING Applicable WDR: Storm Drainage System: WATER USAGE DATA Provide for total water usage at full buildout Number Persons/Day Gallons/Person/Da Total Gallons/Da Domestic Water Usage by Employees/Customers: NOT APPLICABLE Type of Process/Irri gated Lands Total Gallons/Da Process Water Usage: NOT APPLICABLE Process Water Usage: NOT APPLICABLE Irrigation Water Usage: INOTAPPLICABLE Total Gallons Per Day: PROPOSED WELL LOCATION Well Location Address:5225 W 11TH ST I Cit :TRACY Well Location APN:NOT APPLICABLE Well Latitude:SEE SITE PLAN Well Longitude: NOT APPLICABLE Flood Plain Designation:NOT APPLICABLE Well Elevation:I NOT APPLICABLE PROPOSED WELL INFORMATION Well Total Depth(ft):1 I Acres to be Served by Well: Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Depth of Corcoran Clay(ft): Proposed Well Capacity (gal/ft): Estimated Pumping Rate al/min Anticipated Pumping Schedule gal/day): Estimated Annual Extraction Volume(acre-feet): Estimated Cumulative Extraction Volume before January 1,2020 acre-feet): SITING INFORMATION Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: Wastewater Treatment System: NOT APPLICABLE Sources of Contamination: Other Wells: Pond/Lake: Sewer Lines: Stream/River: Animal or Fowl Enclosure: Navigable Waterway: Storm Drainage System] _ Potential Recharge Features: GROUNDWATER INFORMATION Depth (ft): Source/Date of Reference: _ Groundwater Subbasin: Current Depth to Water:NOTAPPLICABLE NOT APPLICABLE _ ❑Cosumnes Subbasin(2-22.16) Highest Depth to Water:NOTAPPLICABLE NOT APPLICABLE ❑ Eastern San Joaquin Subbasin(5-22.01) Lowest Depth to Water: NOTAMLICABLE NOT APPLICABLE ❑Tracy Subbasin(5-22.15) 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 www.sjcehd.corn i of 2