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SAN J OAQ U I N Environmental Health Department <br /> - --C O U .-`T Y----- <br /> �rta;.-fess brows f,_rre. <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number: Application Type: t 45y(itir <br /> Project Address: Z 1 '7 Project APN: <br /> A licant Name: Z- Title: Owvtc Ir <br /> A plicantAddress: tX-6 Cit /Zip: e- <br /> Applicant Phone: Email: e/CLte0D Z)1�t-r»-i :jz'or2/ <br /> Property Owner Name: <br /> A 44 <br /> Property Owner Address: ,� Cit /Zi <br /> Property Owner Phone: Email. <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply: �(,� ❑ Surface Water(Attach Water Rights Information) <br /> Domestic Wastewater Disposal: <br /> Process Wastewater Discharge: <br /> Ponds: Applicable WDR: <br /> Storm Drainage System: <br /> WATER USAGE DATA <br /> Provide for total water usage at full buildout Number PersonslDay Gallons/Person/Day Total GallonslDa <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 /> Irrigation Water Usage: <br /> Total Gallons Per Da <br /> PROPOSED WELL LOCATION <br /> Well Location Address: Cit : <br /> Well Location APN: <br /> Well Latitude: Well Lon itude: <br /> Flood Plain Designation: Well Elevation: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft):j Acres to be Served by ell: <br /> Use of Well: <br /> ❑ 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 allda 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] I I 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 F 209 464-0138 1 www.sicehd.com <br /> 1 of 2 <br />