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P,pUlly <br /> • ' C.g-4 SAN 10A U I N Environmental Health Department <br /> COUNTY-- <br /> \'Z�L�lP Greotness grows her <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 LocationAddress: 30g e C& I I',er I City: /\C�^rr\ O <br /> Well Location APN:j Cr,5 ._ 1C —97 <br /> Applicant Name: I I r , I',r) Applicant Title: ,11 e c <br /> Applicant Address: , . o X, A g I city:1 111 i} <br /> Applicant Phone: . v� 3 , - �-7 Applicant email �,I�e c,11 be• vi►.o r 4 <br /> Property Owner Name: — 1 S e E'. <br /> Property Owner Address: I Ci <br /> Property Owner Phone: Property 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: /Owz) e— Date: a4 �Cr <br /> Statement completed by: 29 Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />