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S AJOAOUIN Environmental Health apartment <br /> Water Usage Information F, <br /> PROJECT INFORMATION a <br /> A licatEonNumber : A lication T <br /> Project dress : - " , �� a �F J Protect APN : <br /> -- A licant Name : - ; ,t 1 Title: INtC; t af , <br /> Applicant Address : � a Ci 1Zi : <br /> Applicant Phone : `�� ; rppppppppEmail : ¢A� � <br /> Pro e O�tiner Name : -ank SIPIriowle tti1Afc c r� un ois <br /> Property. Owner Address : ! ) Ci!Email: <br /> 1Zippod <br /> Property. Owner Pitane : — -- " 7 <br /> EEII <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply : ►t-- [3Surface Water (Attach Water Frights lnforrnafion) <br /> Domestic Wastewater Disposal : i _ \ <br /> Process Wastewater Dischar e : Ponds : Applicable WDR: <br /> c <br /> Storm Draina e S stem : u �,1 <br /> WATER USAGE DATA Total Gallons/Day <br /> Provide for fatal water usage at full buildout Number Persons/ <br /> Da GallonslPerson/ Da <br /> Domestic Water Usage by Employees/Customers : E� la <br /> Type of Processllydigated Lands Total GallonsJDa <br /> Process Water Usa e : c <br /> Process Water Usage : <br /> too <br /> Irri ation Water Usa <br /> Total Gallons Per Day . <br /> PROPOSED WELL LOCATION ' <br /> Cityt f' <br /> Well Location Address : <br /> Well Location APN : Wel ( Lonigitude . <br /> Well Latitude : <br /> Well Elevation : <br /> Flood Plain Desi nation : <br /> PROPOSED WELL INFORMATION <br /> Acres to be Served b We11 : <br /> Well Total Depth (( ft) : <br /> Use of Well : <br /> p Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water .Sdpply ❑ Industrial ❑ Stock <br /> ❑ Other. <br /> Depth of Corcoran Clay (ft) : Estimated Pump Rate allmin : <br /> Proposed Well Capacity alift) : P <br /> Estimaced Annual Extraction Volume acre, feet) : <br /> Amici ated Pumpin Schedule allda : <br /> Estimated Cumulative ExtractioTi Volume before Janua 1 , 2020 acre-feet) ; <br /> SITING INFQRMA <br /> t?ffs�te : Distance To Nearest ft : Onsite : Offsite : <br /> Distance To Nearest ft Itonsite : , Sources of Contamination : <br /> Wastewater Treatment System : pip ", <br /> Other Wells : Stream/ River: <br /> Sewer Lines: = I Navi able Waterwa : <br /> Animal or Fowl Enclosure : > � potential Recharge Features. <br /> Storm Draina e S stem: : <br /> GRQUNDWATER 1NFORMATIQN Groundwater Subbasin : <br /> Depth ft : Source/Date of Reference : <br /> Current Dept t6V�later: ❑ Casumnes Subbasin (2-22 . 16} <br /> Highe�D'epth to Water: <br /> ElEastern San Joaquin Subbasin ( 5 -22 .01 ) <br /> Lot"tiest Depth to Wafer. ❑ Tracy Subbasin (5-22 . 15) <br /> F 209 464 - 0138 %4%r) �v . sjcel � cl . cam <br /> 1868 E . Hazelton Avenue f Stockton , California 95205 I T 209 468 - 3420 - <br /> 1 o1` 2 <br />