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$A N Q Q Q Environmental Health Department <br /> COUNTY <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:1 4902 E. Hildreth Ln. City: Stockton <br /> Well Location APN: 085-300-16 <br /> Applicant Name: Hennings Bros. DdIling Co. Inc. Applicant Title: V P <br /> Applicant Address: 1930 Ladd Rd. I City: Modesto, 95356 <br /> Applicant Phone: 209-545-1185 Applicant email: <br /> Property Owner Name:1 Sean and Danielle Luis corn <br /> Property Owner Address:j 4902 E. Hildreth Ln. City: Stockton <br /> Property Owner Phone: — O -Cc.l j Property Owner email:1 danni dyani <br /> @hotmail.com <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> I 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 /> I hereby certify th t ft inforrfiplion I hayeprovjdeA in this statement is accurate and truthful. <br /> Signed: Date: 7 <br /> Statement completed by: ❑ We I Driller IN Well/Property Owner ❑ Other: <br /> 1868 E.Hazelton Avenue( Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />