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S�N , d 0 0 0 � � Environmental Health Department <br /> _.._C O U IV T Y._-__. <br /> Grc-ocness gro h-s P�aro. <br /> Water Usage Information <br /> i PRQJECT INFORMATION <br /> A lication Number: A lication T e: <br /> Pro ect Adtlress: Pro ect APN: <br /> A licanl Name: Title: <br /> A Ilcant Adtlress: Ci /Zi <br /> A licanl Phone: Email: <br /> Pro a Owner Name: <br /> Pro a Owner Address: Ci /Zi <br /> Pro Owner Phone: Email: <br />' SERVICES INFORMATION <br /> Please rovitle descd lon below: <br /> Wa[ar Supply: p Surtace Water(Attach Weter Rights/nformation) <br /> Domestic Wastewater Dis osal: <br /> Process Wastewater Dischar e: Ponds: A licebla WDR: <br /> Storm Dreina e 3 stem: <br /> WATER USAGE DATA <br /> Provide for fora/water use eat fu//bu/ldout Number Persons/Da Gallons/Person/Da Total Gallons/Da <br /> Domestic Water Usa a b Em to eas/Customers: Ck c..! 1 bC7 c a <br /> T e of Process/Irri atad Lands Total Gallons/Da <br /> Process Water Usa e: <br /> Process Water Usa e: <br /> Irri ffiion Water Usa e: <br /> Total Gallons Per Da <br />� PROPOSED WELL LOCATION <br /> y Well Location Address: Ci <br /> Well Location APN: <br /> Well IatiNde: Well Lon nude: <br /> Flootl PIaIn Desi nation: Well Elevation: <br /> ' PROPOSED WELL INFORMATION <br /> Well Total De h ft: Acres to ba Servetl b Well: <br /> Use of Wall: �Domestic �Irrigation �Smell Public Water Supply D Municipal Public Water Supply D Intlus[rial O Stock <br /> O Other: <br /> De N of Corcoran Cla ft <br /> Pro sed Well Ca aci alit: Estimated Pum In Rate al/min <br /> Amici ated Pum in Schedule al/da Estimated Annual Extraction Volume acre-feet <br /> Estlmatad Cumulative Extraction Volume before Janus 1,2020 acre-feet <br /> SITING INFORMATION <br /> Dlatance To Nearest ft: Onske: Offsite: Distance To Naarast R: Onsite: Offalte: <br /> Wastewater Treatment S stem: Sources of Contamination: <br /> Other Welis: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal or Fowl Enclosure: Nevi able Watervva <br /> Storm Drains e 5 stem: Potential Rechar a Features: <br /> GROUNDWATER INFORMATION <br /> De th R: Sourca/Date of Reference: Groundwater Subbasin: <br /> Current Depth[o Water. p Cosumnes Subbasin(2-22.16) <br /> Highest Depih to Water. O Eastern San Joaquin Subbasin(5-22.01) <br /> Lowest DepM to Water: O Trary Subbasin(5-22.15) <br /> 1868 E. HazalYon Avenue � Stockton. California 95205 � T 209 468-3420 � F 209 464-0138 I www.sicehd.com <br /> l of 2 <br />