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PAZ300279 <br /> SAN lOAQUIN Environmental Health Department <br /> COUNT Y <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> A lication Number: A lication T e: r«.vvnvu=.. <br /> Pro'ec[Address: ti Pro eo[APN: iso-zzo-zzo.iw-zzo-uo.iso-zzo-zw <br /> A Iicant Name:ewm=.r a.,.e,,..m..,uc Title: <br /> A Iicant Address: as lwonmomey sw/.a�so Cit /Zi sen rren=is�.cA same <br /> A Iicant Phone: sto-zzorose Email: y.a®r.ne..vr.a.=om <br /> Pro art Owner Name: 1ne a.ni F.miN TN=� <br /> Pf0 Brt OWnal Addr9aa: 5>P1 N.Cox Raetl OIt /2I Llnaen.CA H5238 <br /> Pro a Owner Phone: Email: <br /> SERVICES INFORMATION <br /> Please rovitle tlescri lion below: ry=n.w..�.r.r..,.,k.Is..v.=+.a. <br /> Water Supply: N/A p Surtace Water(Attach Water R/ghts Information <br /> Domestic Wastewater Dia sal: wA <br /> Process Wastewater Dische e: Ponds: A Iicabla WDR: wA <br /> Storm Drains e S stem: Nmurei oremaoe.on-ar.re�em�=n.x rcyuxea. <br /> WATER USAGE DATA <br /> Provide for total water us a at full bui/lout Number Persons/Da Galions/Person/Da Tolal Gallons/Da <br /> Domestic Water Usa e b Em to ees/Customers: wn w/A <br /> T Ae of Process/IM atetl Lantls Total Gallons/D <br /> Process Water Usa e: wA <br /> Process Water Usa B: N/A _N/A <br /> Ini atlon Water Usa e: wA <br /> Total 6allona Par Da N/A <br /> PROPOSED WELL LOCATION <br /> Well Lacadon Adtlress: N/A Ci rv/A <br /> Well Location APN: ry <br /> Well Latitutle: N/A Well Lon ilutle: ry <br /> Flootl Plain Desi nation: rv/A Well Elevation: ry <br /> PROPOSED WELL INFORMATION A <br /> Wail Total De th ft: wA Acres to be Served b Well: ry <br /> Use Of Well: � Domestic U Imi0alion O Small Public Water Supply D Municipal Public Water Supply D Industrial O Stock <br /> o Other: <br /> De lh of Comomn Cla f[: wA <br /> Pro sed Well Ca acit aVft: wA Estimated Pum In Rate al/min : wA <br /> Amici atetl Pum in Schedule al/da N/A Estimaletl Annual Eztracfion Volume acre-feet: ry <br /> Estimated Cumulative Extraction Volume before Janus 1 2020 acre-feet: rv/A <br /> SITING INFORMATION <br /> DiEtanee To Nearas! ff: Onsite: Offsite: Distance To Nearest ft: Onsite: Offsite: <br /> WastewaterTreatmentS stem: N/A wA Sources of Contamination: WA wA <br /> Gther We11S: WA WA Pond/La Ke: N/A WA <br /> SBWer Linea: N/A N/A $Ir6 m/RIVBC WA <br /> Animal Or FOWI EOCIOSUre: WA N/A Navl able Waterwa WA N/A <br /> Storm Dmin e S stem: wA wA Potential Recha a Features: wA NM <br /> GROUNDWATER INFORMATION <br /> De th ft: Source/Date of Reference: Orountlwater Subbasin: <br /> Current DepM[o Water: N/A N/A O Cosumnes Subbasin(2-22.16), <br /> Highest Depth[o Water: N/A N/A o Eas[em San Joaquin Subbasin(5-22.01) <br /> Lowest Depth[o Water: N/A N/A p Tra Subbasin 5-22.15 <br /> 1668 E. Hazelton Avenue I Stockton, California 95205 I T 209 466-3420 I F 209 464-0138 I www.sicehd.com <br /> l of 2 <br />