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COUNTY Environment.. Health Department Water Usage Information PROJECT INFORMATION PROPOSED WELL LOCATION Well Location Address: Application Number: Application Type: Well Location APN: Project Address C1.6' 'E CWP45A Project APN: / Well Longitude: Applicant Name--TP—MA 6&AWE-T- Title: Applicant Address: 2.-f? 0 IG2444 Awt—w4— AV l City/Zip: / Acres to be Served by Well: Applicant Phone: c ` - 3 Ematl: *1 �' z« ❑ Small Public ter Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): / Property Owne-rName: l Estimated Pumping Rate (gal/min): Anticipated Pumping Schedule (gal/day): Property Owner Address:1- —• 4!1/'A=:w o6 City/Zip: Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): Property Owner Phone: VS-- Email: Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: SERVICES INFORMATION Sources of Contamination: Other Wells: Please provide description below: Sewer Lines: Stream/River: Water Supply: IV ❑ Surface Water (Attach Water Rights Information) Domestic Wastewater Disposal: Potential Recharge Features: Process Wastewater Dischare: Ponds: Applicable WDR: Groundwater Subbasin: Storm Drainage System: ❑ Cosumnes Subbasin (2-22.16) ❑ Eastern San Joaquin Subbasin (5-22.01) ❑ Tracy Subbasin (5-22.15) WATER USAGE DATA Lowest Depth to Water: Provide `or totai water usage at foil buildout Number Persons/Da Gallons/Person/Day Total Gallons/Da Domestic Water Usage by Employees/Customers- Type of Process/Irrigated Lands Total Gallons/Da Process Water -Usage: Process Water Usage: Irrigation Water Usage: 'Total Gallons Per Day: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com. 1 of 2 PROPOSED WELL LOCATION Well Location Address: l' I City:1 Well Location APN: Well Latitude: / Well Longitude: Flood Plain Designation: Well Elevation:1 PROPOSED WELL INFORMATION Well Total Depth (ft): / Acres to be Served by Well: Use of Well: ❑ Domestic ❑ Irrigation ❑ Other: ❑ Small Public ter Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Depth of Corcoran Clay (ft): / Proposed Well Capacity (gal/ft): l Estimated Pumping Rate (gal/min): Anticipated Pumping Schedule (gal/day): Estimated Annual Extraction Volume (acre-feet): Estimated Cumulative Extraction Volume before January 1, 2020 (acre-feet): SITING INFORMATION 4 Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Sources of Contamination: Other Wells: Pond/Lake: Sewer Lines: Stream/River: Animal or Fowl Enclosure:l Navigable Waterway: Storm Drainage System:1 System: Potential Recharge Features: GROUNDWATER INFORMATION Depth (ft): Source/Date of Reference: Groundwater Subbasin: Current Depth to Water: ❑ Cosumnes Subbasin (2-22.16) ❑ Eastern San Joaquin Subbasin (5-22.01) ❑ Tracy Subbasin (5-22.15) Highest Depth to Water: Lowest Depth to Water: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com. 1 of 2