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SAN;J O A Q U 11.1 Envi ronmenta, Health Department <br /> COUNTY <br /> OOOig�" <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number: I Application Type: Stz E�?ctUf � <br /> Project Address: vz:j.4 Project APN: C"Z p—l%-k(J" <br /> p <br /> Applicant Name: S- <—,\c-k_v.,tAo I? L-VjI,- S Title: - <br /> Applicant Address: k 8c_ G C_ City/zip:. <br /> Applicant Phone: Z<�-,c1 Email: �ri�c��c.c�ale�c-"�. •� L <br /> Property Owner Name: <br /> Property Owner Address: `Z Wks .—j C? L,_v City/zip: C»' C �S <br /> Property Owner Phone: " Z'� Email: T �c��� Q�•Kpp.. c� .,� <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply: L.�t -T c,� ��c � <br /> ❑ Surface Water(Attach Water Rights Information) <br /> Domestic Wastewater Disposal: <br /> Process Wastewater Discharge: Ponds: Applicable WDR: <br /> Storm Drainage System: <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number Persons/Da Gallons/Person/Day Total Gallons/Da <br /> Domestic Water Usage by Employees/Customers: <br /> Type of Process/Irrigated Lands Total Gallons/Da <br /> Process Water Usage: <br /> Process Water Usage: <br /> Irri ation Water Usage. <br /> Total Gallons Per Day: <br /> PROPOSED WELL LOCATION <br /> Well Location Address: -j( City] <br /> Well Location APN: <br /> Well Latitude: Well Lon itude: <br /> Flood Plain Desi nation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total De th(ft):l 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 of Corcoran Clay(ft): <br /> Proposed Well Capacity (gal/ft): Estimated Pumping Rate gal/min): <br /> Anticipated Pumping Schedule(gal lda ): 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 Waterwa : <br /> Storm Drainage System:j 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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 209 464-0138 1 <br /> 1 of 2 <br />