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SA NJ OAQ U I N Environmental Health Department <br /> _.....__..C O U N T Y._..,._.... <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 /> 11VEi<rt:-LP> ";AN"ER#N1"Oi1J ON <br /> Well Location Address: 1739 Piper Place City: Imy <br /> Well Location APN: 255-310-34 <br /> Applicant Name: Hennings Bros. Drilling Co., Inc. Applicant Title: <br /> Applicant Address: 1930 Ladd Rd. I City: Modesto 95356 <br /> Applicant Phone: 209-545-1185 Applicant email:wells4u hennin sbro . <br /> Property Owner Name: Manuel Rosas <br /> Property Owner Address: City Trac 95377 <br /> Property Owner Phone: 209-275-9308 Property Owner email:.r h i . m <br /> Aff- <br /> EXEMPTION�CCRITERIA k= =s> ,r arRWIMI� MMI <br /> ty , ' F <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: a Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: 650.000 <br /> Existing well estimated annual extraction volume: 0 <br /> Total Annual Domestic Use Volume: 650,000 <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 t the infor a on L h ve provided in this statement is accurate and truthful. <br /> -Signed: Date: I Oct. 8 2018 <br /> Statement completed b : X.] 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 />