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$QNAJQQQU�N environmental Hea1tF>t Department <br /> —COUNTY <br /> G._a�„c x, y, ..... Pn.,,. <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> A Ilcation Number: A lication T e: <br /> Pro ect Atldresa: we Ra,e.«k,«,ca same Pro ect APN: s-+eo<so-Doo <br /> A Iicant Name: m of nrnoie F Title: Praleu seroy rn000ge. <br /> A Iicant Address: s Ci /Zi <br /> A Iicant Phone: noel v+sazas F Email: miu.eel.emae®ue,ey�omo.«r.. <br /> Pro a Owner Name: v <br /> Pro a Owner Atldress: +sz Frenk wee cime�c Cit/ZI s+«wou,cn aszos <br /> Pro a Owner Phone: (zoa>v+s-azas Email: ,� Die®�.��.vv®=mo.00.., <br /> SERVICES INFORMATION <br /> Please rovitle descd tion below: cu...m....+.r.omo.�.®n®.mn ...on.wa..,owa nke+o eeeneon ens enn o osw wen. <br /> Water Supply: p Surface Water(Attach Water Rights Information) <br /> Domast{c Wastewater Dis Deal: sevnc-renk wun Leacn nnac <br /> Process Wastewater Dische e: Ponds: A Ilceble WDR: <br /> Storm Drains e5 stem: sror,.,..,o,o.goes m.ougn..a+.non a.ve.um nese vo,w. <br /> WATER USAGE DATA uta <br /> Provide for tote/water use a et fu//bui/lout Number Persona/Da Gallons/Peraon/Da Total Gallons/Da <br /> Domestic Water Usa e b Em to ass/Customers: <br /> Ts a of Procass/Irri sled Lands Total Gallons/Da <br /> Process Water Usa e: <br /> Process Water Usa e: <br /> IM anon Water Usa e: <br /> Total Gallons Per Da <br /> PROPOSCO WELL LOCATION <br /> Well LOcatlOn Addrea8: 3550 3.Rf 98 E Fronlaga Rtl. (il Stockbn.CA <br /> Well Location APN: + ao-000 <br /> Well Latitude: avezarrs Well Lon itutle: -+zvzza+se <br /> Flcotl Plain Desi nation: R Well Elevation: areae <br /> PROPOSlO WELL INFORMATION <br /> Well Tolal Da tll ft: soo Acres to be Servetl b Wall: s. <br /> Use of Wall: o Domestic o Irrigation �Small Public Wafer Supply O Municipal Public Water Supply lsindustrial o Stock <br /> �Other: <br /> De th of Corcroren Cla ft: RA <br /> Pro Deed Well Ca aci alttt: Estimatatl Pum In Rale al/min : ss <br /> Amici atetl Pum in Schedule al/da Es[imatetl Annual Extraction Volume acre-fee[ <br /> Estimatetl Cumulative Extraction Volume before Janus t,2020 acre-feet <br /> SITING INFORMATION <br /> Dietenea To Nearest TL: Onsite: Offsite: Distance To Nearest R: Onsite: Offsite: <br /> Wastewater Treatment S atom: Sources of Contamination: <br /> Other Wells: ssrt PonWLake: <br /> Sewer Liners: Stream/River: <br /> Animal or Fowl Enclosure: Nevi able Waterwa <br /> Storm Drains e S stem: Potential Rachar a Features: <br /> GROUNDWATER INFORMATION <br /> De th ff: Source/Date of Reference: Groundwater Subbaain: <br /> Current Depth to Weter: p Cosumnas Subbesin(2-22.1 B) <br /> Hi9hea[Depth to Wa[ec p Eastern San Joaquin Subbaain(5-22.Ot) <br /> Lowest Depth to Water: p Tracy Subbesin(5-22.'15) <br /> 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0'138 � www.sicehd.com <br /> t of 2 <br />