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S A N e 10 A Q U I N Environmental Health Department <br /> - <br /> - --COUNTY--- <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> A lication Number: A lication T e: <br /> Pro'ect Address: Y2n yac_ L Pro'ect APN: Z3q- <br /> A licant Name: Title: -)f1(Or <br /> A plicant Addres G _ Ci /Zig <br /> Applicant Phone: )Q a _yI& Email: en <br /> Property Owner Name <br /> Property Owner Address: City/zip. <br /> Property D Owner Phone - <br /> Ema1 <br /> SERVICES INFORMATION <br /> Pleaserovide descri tion below: <br /> Water Supply: �C✓ U._�-�'\ <br /> V Surface Water(Attach Water Rights Information) <br /> Domestic Wastewater Dis osal: ��cy1 elft <br /> Process Wastewater Dischar e: Ponds: IA licable WDR: <br /> Storm Drainage System: <br /> WATER USAGE DATA <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 /> Process Water Usa e: Type of Process/Irrigated Lands Total Gallons/Da <br /> Process Water Usa e: <br /> Irri -tion Water Usage: !t/e►sive <br /> Total Gallons Per Da <br /> PROPOSED WELL LOCATION <br /> Well Location Address: _ � Ci <br /> Well Location APN: S <br /> Well Latitude: Well Lon itude: <br /> Flood Plain Desi nation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total De th ft: 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 <br /> ther-De th of Corcoran Clay(ft): <br /> Pro osed Well capacity (gal/ft): Estimated Pumping Rate (gal/min): <br /> Antici -ted Pum in 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 S stem: Sources of Contamination: <br /> Other Wells: Pond/Lake: <br /> Sewer Lines: Stream/River: b0 <br /> Animal or Fowl Enclosure: Navigable Waterway: <br /> Storm Drainage System:j System: Potential Recharge Features..- <br /> GROUNDWATER <br /> eatures:GROUNDWATER INFORMATION <br /> Current Depth to Water: De th ft : Source/Date of Reference: Groundwater Subbasin: <br /> Highest Depth to Water: <br /> Cosumnes Subbasin(2-22.16) <br /> 5 11 nal o�GYJ b ® Eastern San Jcaquin Subbasin(5-22.01) <br /> Lowest Depth to Water: f a <br /> a BSc ❑ Tracy Subbasin(5-22.15) <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br /> 1 of 2 <br />