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'A; �PA9J 2 � b1 <br /> c`Environmental dealt epartme t <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number: Application Type: <br /> Project Address: uN-` oY ,h 0151Project APN: <br /> Applicant Name: Title: <br /> Applicant Address: 4 ^ City/Zip: y53( <br /> Applicant Phone: ,kc) Email: <br /> Property Owner Name: 4b,\, X04 <br /> Property Owner Address: —1 c Cit /Zi :(h;\re— V, CA c 53h <br /> Property Owner Phone: aUc•, Email: <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply Cc��':w �a� Wc�kf <br /> ❑ Surface Water(Attach Water Rights Information) <br /> Domestic Wastewater Disposal: C�k\j St';�rz� <br /> Process Wastewater Discharge: Ponds: Applicable WDR: <br /> Storm Drainage System: �,��h�c• <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number Persons/Da Galions/person/Day Total Gallons/Da <br /> Domestic Water Usage by Employees/Customers: n �VN k ,�-• ,� <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: I Cit <br /> Well Location APN: <br /> Well Latitude: Well Lon itude: <br /> Flood Plain Designation: Well Elevation: <br /> PROPOSED WELL INFORMATION �J C)l`_ <br /> Well Total Depth (ft): I Acres to be Served by Well: <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity (gal/ft): Estimated Pumping Rate (gal/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: 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 F. Hazelton Avenge 1 Stockton, California 95205 1 T 209 468-3420 1 F 2.09 464-01.38 1 wxw.Sigoy,org/EHf- <br /> 1 of 2 <br />