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SAN 10A Q U I N Environmental Health Department <br /> —COUNTY-- <br /> Greatness grows h <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: E?O t'Lr' J Zj City: ©� i <br /> Well Location APN: C.S'S`-O20 —0,2 0 OrDO <br /> Applicant Name: ,z? Applicant Title: (^`//�T <br /> Applicant Address: U ' �'- ; City: ,/7' ��C <br /> Applicant Phone: __2 c- 7— cj ci Applicant email: O!'e <br /> Property Owner Name: <br /> Property Owner Address: I - I vc City: i ocr;7`G� <br /> Property Owner Phone: �� _ Property Owner email: <br /> LEXEMPTION 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 /> ee-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 /> EI 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 /> herebV certify that the information I have provided in this statement is accurate and truthful. <br /> Signed: Date: 7 <br /> Statement completed by: Well Driller ElWell/Property Owner ElOther: <br /> 1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />