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WP0038398
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038398
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Entry Properties
Last modified
6/10/2019 12:35:50 PM
Creation date
5/24/2019 3:37:04 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038398
PE
4366
STREET_NUMBER
23350
Direction
N
STREET_NAME
BRUELLA
STREET_TYPE
RD
City
ACAMPO
Zip
95220-
APN
00734004
ENTERED_DATE
6/6/2018 12:00:00 AM
SITE_LOCATION
23350 N BRUELLA RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
AGooderham
Supplemental fields
CYEAR
2018
Tags
EHD - Public
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SAN J OAQU I N Environmental Health Department <br /> — COUNTY <br /> Grectness grows herr. <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: 5"0 , e/% City: <br /> Well Location APN: <br /> Applicant Name: <e (���sS Applicant Title: <br /> Applicant Address: o b,x ity: w 00A', ,� <br /> Applicant Phone: 3 _ 31 a-o Applicant email: <br /> Property Owner Name: V)'64-or e <br /> Property Owner Address: ,,, 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: &k_ <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 certifyAhatthe information I have provided in this statement is accurate and truthful. <br /> Signed: Date: —� <br /> Statement completed by: ❑ Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />
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