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SAN JOAQWN Environmental Health Department <br /> -- - COUNTY -- - <br /> (�, rec, trress <br /> Water Usage Information <br /> PROJECT INFORMATION <br /> Application Number : Application Type : <br /> Pro ect Address : Project APN : <br /> Applicant Name : Title : <br /> Applicant Address : City/Zip : <br /> Applicant Phone : Email : <br /> Property Owner Name : " Ma Vj <br /> Property Owner Address : City/Zip: <br /> Property Owner Phone : , 5 Email : kar <br /> � <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 : Ponds : �Applicable WDR : <br /> Storm Drainage Sy stem : <br /> WAMR USAGE DATA <br /> Provide for total water usage at full buildout Number Persons/Da Gallon s/Person / Day Total Gallons/Da <br /> Domestic Water Usage by Employees /Customers : WA <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 : City: <br /> Well Location APN : <br /> Well Latitude : Well Longitude : <br /> Flood Plain Designation : Well Elevation : <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth (ft) : A 4 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): 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 ) d 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 : 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 . s0cehd . com <br /> 1 of 2 <br />