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SAN J OAQ U I N Environmental Health Department <br /> s <br /> --- -COUNTY--- <br /> Greatness groo. , ! <br /> FSP <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: 00(- h\�Y, 7y' UO City: <br /> Well Location APN: <br /> Akv <br /> Applicant Name: t5{ Cec 4 e-p -'r , Lr;f! Wpiicant Title: <br /> Applicant Address. i3�� 13,� City: C.5 c w l;, <br /> Applicant Phone: Zjcj f g,�,-7S Ll( Applicant email: <br /> Property Owner Name: o rnctu - Reube_'— <br /> Property Owner Address: J G �� 1,}�t City: � C-0 e e"\.Property Owner Phone: 510--2 ,90 779 Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well mets any of the following Exemptions: <br /> V Pell 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 /> Keplacement 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 /> 24how 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 th e infor ati n I have provided in this statement is accurate and truthful. <br /> Signed: Date: <br /> Statement competed b : ell Driller ❑ Well/ y 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 />