Laserfiche WebLink
SA6J0A0UIN <br /> 2 ..�.., .x. Environmental Health Department <br /> uli% ' —COUNTY— <br /> crvor� <br /> Greatnes yrovrs 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 <br /> Well Location Address: I City: <br /> Well Location APN: 2 - O`tD- <br /> Applicant Name: Applicant Titie: U ►1tr <br /> Applicant Address: i ri City: T <br /> Applicant Phone: I o 331- 1330 Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> ,�a <br /> EX <br /> 1' iQ�_r a s zC#pSt q � <br /> Well meets any of the following Exemptions: <br /> ❑ Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumne 3 Subbasin (5-22.16) <br /> ❑ New well owner will be a de minimis extractor: maximum two acre-feet(651,702 gallons)or I ss 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: XServe an existing residence ❑ Irrigate residential land ape <br /> New well estimated annual extraction volume: 1e-g s 4�t.r,+ 2a4c ee -brie• <br /> Existing well estimated annual extraction volume: I t <br /> Total Annual Domestic Use Volume: <br /> ❑ Public agency that substantially meets or exceeds these requirements through another reqL irement 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 cou ty. <br /> I hereb certify that the information I have provided in this statement is accurate and truthful. <br /> Si ned: --"� <br /> Date: ! 19 <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 Avw.sicehd.com <br />