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D r , <br /> . <br /> )oP�� ItSANSAN JOAQUIN Environmental Health Department <br /> COUNTY - <br /> . - <br /> Greatness grows here . N /A <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number : Application Type : <br /> Project Address : Project APN : <br /> Applicant Name : Title : <br /> Applicant Address : City/Zip : <br /> Applicant Phone : Email : mkeith@assurance-group . com <br /> Property Owner Name : <br /> Property Owner Address : Cit /zip : <br /> Property Owner Phone : Email : mkeith@assurance-group . com <br /> SERVICES INFORMATION <br /> Please provide description below: <br /> Water Supply : 1499 Huntington Dr . #305 ❑ 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 / Da 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 /> Irrigation Water Usage : <br /> Total Gallons Per Day : <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) : 1 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/day): I 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 : 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 Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sicehd . com <br /> 1 of 2 <br />