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SAN J Q Q Q Q N Environmental Health Department <br /> COUNT Y <br /> �Q�!,Grios�"P Gl-cotness grows (sere. <br /> Well Exemption Statement <br /> Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit <br /> additional information prior to the issuance of a permit by the Environmental Health Department. This form must be <br /> completed to document the exemption criteria applicable for the new well application. <br /> VNELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: 2 7 ' OW-C/y\ S P_j City: Gc/(_ l 0 V-\ <br /> Well Location APN; TL •- (t7 -- l <br /> Applicant Name: _,t vvut i n f i ntTitle: 0wv\4_,Y' <br /> Applicant Address: t o V I 5 1 v,k vj 1 A-x)-a it 44 r City: 'moo _A-PSt-o <br /> Applicant Phone: IL 7 Lo Applicant email: VA,_cj C usfl e-r--e, <br /> Property Owner Name: A a��� ✓+� v, <br /> Property Owner Address: City: <br /> Property Owner Phone: 2Ll)cf ! I Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> ❑ Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin (5-22.16) <br /> New well owner will be a de minimis extractor: maximum two acre-feet (651,702 gallons)or less per year being <br /> extracted for domestic purposes only. <br /> ❑ Replacement well with same extraction as the existing well that it is replacing. To meet this exemption the existing <br /> well must be destroyed under permit or continue to be used for domestic purposes with total domestic extractions <br /> remaining two acre-feet or less per year. <br /> Purpose/use of existing well: ❑ Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: <br /> Existing well estimated annual extraction volume: <br /> Total Annual Domestic Use Volume: <br /> ❑ Public agency that substantially meets or exceeds these requirements through another requirement of the law. In <br /> order to be exempt, the applicant shall document the laws that substantially meet or exceed these requirements <br /> and how the requirements of those laws were met. <br /> ❑ A city or county municipal well to provide water supply solely for residents of the city or county. <br /> hereby ce e i m rovided in this statement is accurate and <br /> lI truthful. <br /> Si ned: Date: 3 1 <br /> Statement completed by: 1AWell Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />