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rarnc <br /> SAN t ] 0 A QU IN En ironri samm. 1 6 uearulh DeparL it <br /> µ .:.:.,..... _ C 0 U N T Y ....w..,....._. <br /> ' G F C it t n c 3 a crows h e r c . coo <br /> - _ <br /> o <br /> V\Satev Usage � nformadon RA P? <br /> PROJECT INFORMATION <br /> Application Number: Application Type : ° ep #Mv <br /> Project Address : ' _ Project APN : �- <br /> Applicant Name : ' Ale r04 4 74 414,1A Title : <br /> Applicant Address : City/Zip : m ig:' <br /> Applicant Phone : �� - Email : tl ° <br /> Property Owner Name : <br /> Property Owner Address : r y City/Zip : <br /> Property Owner Phone : Email : <br /> 0 ,10614 14,0121 <br /> CES INFORMATION <br /> Please provide description below : <br /> Water Supply : , <br /> � 4t � ElSurface Water (Attach Water Rights Information ) <br /> Domestic Wastewater Disposal : <br /> Process Wastewater Discharge : Ponds : T Applicable WDR : <br /> Storm Drainage System : <br /> WATER LISAGt DATA <br /> Provide for total water usage at full buildout Number Persons/Day Gallons/Person /Day Total Gallons/Day <br /> Domestic Water Usage by Employees/Customers : <br /> Type of Process/Irrigated Lands Total Gallons/ Day <br /> Process Water Usage : <br /> Process Water Usage : <br /> Irrigation Water Usage : <br /> Total Gallons Per Day . <br /> ELL LOCATION <br /> Well Location Address : - ` Ci : <br /> Well Location APN : e <br /> Well Latitude : I ff Well Longitude . <br /> Flood Plain Designation : Well Elevation : <br /> PROP ED WELL INFORMATION <br /> Well Total Depth (ft) : 1 Acres to be Served by Well : <br /> Use of Well : ❑ Domestic ❑ Irrigation ❑ Small ubli Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay (ft) : <br /> Proposed Well Capacity (gal/ft): Estimated Pumping Rate (gal/min): <br /> Anticipated Pumping Schedule (gal/day): 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 /> Depth ft : 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 /> 14 , <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 -3420 F 209 464 -0138 www . sicehd . com <br /> 1 of 2 <br />