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SAN JOAQUIN Environmental Health Department <br /> CO lJ lel T Y <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number : Application Type : <br /> Project Address : I , Project APN : 3 LU B <br /> Applicant Name : PQ 3Yj14. . Title : <br /> Applicant Address : s - city/zip: <br /> Applicant Phone : Email : .t (z) ! �. , <br /> tael <br /> Property Owner Name : Ijk. < <br /> Pro e - Owner Address : 41 - ,vu, ..\. ' Ci IZi <br /> Property Owner Phone : S � c7 - �; 1, Email : <br /> SERVICES INFORMATION <br /> Please provide description below : <br /> Water Supply : ` ❑ Surface Water (Attach Water Rights Information ) <br /> f <br /> Domestic Wastewater Dis osal : N <br /> Process Wastewater Discharge : Ponds : _ A licable WDR : <br /> Storm Drainage System : y�/4 <br /> WATER USAGE DATA -amu <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 : I city: <br /> Well Location APN : <br /> _ Well Latitude . Well Longitude : _ <br /> Flood Plain Designation : Well Elevation : <br /> PROPOSED WELL INFORMATION <br /> Well Total De th (ft) : 1 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 /> _ <br /> Depth of Corcoran Clay (ft) : <br /> Proposed Well Capacity (gal/ft): _ Estimated Pumping Rate (gal/min): <br /> Anticipated Pumping Schedule al/da _ 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 /> De <br /> Ixtth (� : 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 Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . s ' cehd . com <br /> 1 of 2 <br />