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WP0039565
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039565
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Entry Properties
Last modified
10/1/2019 11:40:26 AM
Creation date
10/1/2019 11:34:20 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039565
PE
4380
STREET_NUMBER
24405
Direction
N
STREET_NAME
LEADSTONE
STREET_TYPE
DR
City
ACAMPO
Zip
95220-
APN
00536003
ENTERED_DATE
4/29/2019 12:00:00 AM
SITE_LOCATION
24405 N LEADSTONE DR
P_DISTRICT
004
QC Status
Approved
Scanner
TSok
Tags
EHD - Public
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t <br /> SAN J O A Q U I N Environmental Health Department <br /> —COUNTY-- <br /> Greatness 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: l I L e"\C S }c'�)c PC. I City: Cc, <br /> Well Location APN: <br /> Applicant Name: \;i I 1 c I u ; I I `' Applicant Title: ;c e , r s,le p,,V <br /> Applicant Address: 2.c 4 1 City: L <br /> Applicant Phone: 3i1 cl -7-7q Applicant email: <br /> Property Owner Name: , V.t? <br /> Property Owner Address: 6,(j Dc I City: L< <br /> Property Owner Phone: TProperty 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: <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 /> I hereby certify that the information I have provided in this statement is accurate and truthful. <br /> Signed: � 7 ma y` Date: Z� <br /> Statement completed by: 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 />
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