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SANJOAQUIN Department <br /> Environmental Health De <br /> —COUNTY <br /> `�uepa�'I %pra,Utnf•ii �,'_`•v: r12'!. <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: City: 3 <br /> Well Location APN: — — O <br /> Applicant Name: Applicant Title: <br /> Applicant Address: IV S1 tam U City: <br /> ApplicantPhone: 20 1950 I Applicant email: <br /> Property Owner Name: <br /> Property Owner Address-11Clh+: <br /> Propeqy Owner Phone:j Owner email: <br /> WAMM 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 /> 11 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.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 /> Purposeluse of existing well: Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: �i S o dGr>✓ ��" P?'*" Yah' <br /> Existing well estimated annual extraction volume: <br /> rr � <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 /> p A city or county municipal well to provide water supply solely for residents of the city or county. <br /> I hereb ce ' that the in ormation I have provided in this statement is accurate and truthful. <br /> A7 Z4 <br /> Si ned: <br /> S Date, ��• 2 <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 />