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z ` "tet <br /> SAN JOAQUIN Environmental Health Department <br /> COU NTY- <br /> c� P, Greatness grows here. <br /> WPI EYP-mntinn State-mP--nt <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: 90o1 C o,d 1 e RV. City: L . <br /> Well Location APN: <br /> Applicant Name: Applicant Title: We 11 <br /> Applicant Address: 2.0 - &nx Aa_ I City: <br /> Applicant Phone: - g- Applicant email:Naljec,1 S tx iOlAk ne + <br /> Property Owner Name: f,\j c, `�"�c r \� <br /> Property Owner Address: a0� Lc6k K17 City: Lod <br /> Property Owner Phone: - y Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> -K 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 /> RanInramant wall with (zama avtrartinn aS tha avidinn wall that it is ranlarinn Tn maat thilz aYamntinn tha avi0inn <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: di-Q) )t SS +W C,n 4 u a ol C r e T-c.e-- <br /> Existing well estimated annual extraction volume: ('CSS l k i +ua G C e-e -�f C+ <br /> Total Annual Domestic Use Volume: Lr S -1-h 4 n w o G C r e <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 that the information I have provided in this statement is accurate and truthful. <br /> -SignedL-2: 'C UL"C Date: I <br /> Statement completed by: 3 Well 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 />