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WP0038640
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038640
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Entry Properties
Last modified
4/11/2019 9:31:24 AM
Creation date
4/11/2019 9:29:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038640
PE
4366
STREET_NUMBER
2820
Direction
W
STREET_NAME
FOREST LAKE
STREET_TYPE
RD
City
ACAMPO
Zip
95220-
APN
00306031
ENTERED_DATE
8/9/2018 12:00:00 AM
SITE_LOCATION
2820 W FOREST LAKE RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
AMeuangkhoth
Supplemental fields
CYEAR
2018
Tags
EHD - Public
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z <br /> i <br /> SAN ]OAQ U I N Environmental Health Department <br /> ---COUNTY— <br /> Greatness <br /> -COUNTYGreatness grows here. <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 .2- City: L«C <br /> Well Location APN:j o03 - © 3 / <br /> Applicant Name: ke,,/-L, Applicant Title: <br /> Applicant Address: po 1 ity: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: 0( T v<� <br /> Property Owner Address: e- City: <br /> Property Owner Phone: Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets <br /> meets any of the following Exemptions: <br /> IK <br /> Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15)Tosumnes 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 certif the inf rmation I have provided in this statement is accurate and truthful. <br /> Signed: l Date: <br /> Statement completed b : ❑ Well Driller ❑ Well/Property Owner Wither: <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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