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WP0038031
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038031
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Entry Properties
Last modified
12/27/2018 11:26:28 AM
Creation date
9/27/2018 8:29:37 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038031
PE
4366
STREET_NUMBER
18704
Direction
E
STREET_NAME
COPPEROPOLIS
STREET_TYPE
RD
City
LINDEN
Zip
95236-
APN
18321002
ENTERED_DATE
3/9/2018 12:00:00 AM
SITE_LOCATION
18704 E COPPEROPOLIS RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
DAfonskaia
Supplemental fields
CYEAR
2018
Tags
EHD - Public
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1 <br /> r <br /> SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> r <br /> Greatness ows her, <br /> cu' 9 <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 /> WELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: '% b-1 0 q F Cupperc.,,,0o'j ) f11A City:' d-e h <br /> Well Location APN: 3_ t p- }'L <br /> Applicant Name: '3',r �z4p, >,0� u h Applicant Title: U c,, <br /> Applicant Address: ; ca LI p �,, �, o i I !� City: „�dl,.✓' <br /> Applicant Phone: ,Z- (j3 g,I Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: - V” City: <br /> Property Owner Phone: 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 certify that the information I have provided in this statement is accurate and truthful. <br /> Signed: `� Date: <br /> Statement completed by: IAWell Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />
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