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SAN-IJOAQUIN Environmental Health Department <br /> C 0 U N"F'Y---- <br /> Grcctne.,;s Grows here, <br /> PA o ® L 4 <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> ApplIcation Number: ApplIcation Type: <br /> Project Address: 7—q I CA f2-j>1'r4 r+I- Project APN: t 7, <br /> Applicant Name: L, Tltla: <br /> Applicant Address:l City/ZIp,, 9 Ic ILC) <br /> ARE![cant Phone:1 <br /> !� <br /> Em a 11:AA I (\A <br /> Pro pe&,Owner Name: k A n't j\.j r—L <br /> Property Owner Address; L\ 6 <br /> 2 Ca <br /> Property Owner Phone: -1-0"1 Lk(.o �l <br /> SERVICES INFORMATION <br /> Please provide clesorlptlon below: <br /> Water Supply: c A- L El Surface Water(Mach Water Rights Infortnatlon) <br /> Domestic Wastewater Disposal: 14 -- <br /> Process Wastewater DlschargG: I Applicable WDR,, <br /> Storm Drainage System; I <br /> WATER USAGE DATA <br /> Pro v1do for total wafer usage at full bultdout Number Persons/Day Gallons/PersonlDay Total Gallons/Day <br /> Domestic Water Usage by Employoes/Custamers: 1. 11 1 — <br /> Type of ProcessA rri2ated Lands Total Gallons/Day <br /> Process Water Usage: <br /> Process Water Usage: I <br /> Irrigation Water Usage: <br /> TotalGallonsPer Day: <br /> Well Location Address: PROPOSED WELL LOCATION — I CRY:1 <br /> Well Locatlon AM <br /> Well Latitude: Well Longi"if <br /> Flood Plain Designation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft);[-_--T— Acres to be Served by Well;j- <br /> -Uwofwol domestic—[]-Irdgation—EI-Small-Publie-Water Supply—n-Municlpal-Publlo-Water-Supply—B-Industrial—o-stoc� <br /> IJ Other: <br /> Deptl- of Corcoran Cla ft): <br /> Proposed Well capqcii allft. I Estimated Pum In Rate(gal/min): <br /> Antiolpated Pumping Schedule allda Estimated Annual Extraction Volume(acre-feet): <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> MING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offelte: Distance To Nearest(ft Onsite: Offsite: <br /> Wastewater Treatment System: Sources of Contamination: <br /> Olher Wells: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Anlma(or Fowl Enclosuro: Navigable Waterway: <br /> Storm Drainage System:[ Potential Recharge Features:j <br /> GROUNDWATER INFORMATION <br /> Deptliffit): Source/Onto of Reference; Groundwater Subbasin: <br /> Current Dep(h to Water: 0 Cosumnes Subbasin(2-22.16) <br /> Hlghest Depth to Water: U Eastern San Joaquin Subbasin(5-22,01) <br /> Lowest Depth to Water: Ej Tracy Subbasin(6-22,15) <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 rp <br /> 1 or 2 <br />