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SANJOAQUIN COUNTY Environmental Health Department Well Exemption Statement Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit additional information prior to the issuance of a permit by the Environmental Health Department. This form must be completed to document the exemption criteria applicable for the new well application. WELL LOCATION AND OWNER INFORMATION Well meets any of the following Exemptions: ❑ Well Location Address: 3C: �� S e 5 t c_ City: L Well Location APN: C' well must be destroyed under permit or continue to be used for domestic purposes with total domestic extractions remaining two acre-feet or less per year. Purpose/use of existing well: ❑ Serve an existing residence ❑ Irrigate residential landscape Applicant Name: '�'n Ile I Applicant Title: \'j s ,) le r Applicant Address: 9 C) ❑ I City: (,- ;Applicant ApplicantPhone:- 77c Applicant email: .;)1<,\f,11,,,q A city or county municipal well to provide water supply solely for residents of the city or county. Property Owner Name: Property Owner Address: 3c: -, ,e 1 City: Lcd') Property Owner Phone: Property Owner email: EXEMPTION CRITERIA Well meets any of the following Exemptions: ❑ Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin (5-22.16) New well owner will be a de minimis extractor: maximum two acre-feet (651,702 gallons) or less per year being extracted for domestic purposes only. ❑ Replacement well with same extraction as the existing well that it is replacing. To meet this exemption the existing well must be destroyed under permit or continue to be used for domestic purposes with total domestic extractions remaining two acre-feet or less per year. Purpose/use of existing well: ❑ Serve an existing residence ❑ Irrigate residential landscape New well estimated annual extraction volume.- olume:Existing Existingwell estimated annual extraction volume: Total Annual Domestic Use Volume: ❑ Public agency that substantially meets or exceeds these requirements through another requirement of the law. In order to be exempt, the applicant shall document the laws that substantially meet or exceed these requirements and how the requirements of those laws were met. ❑ A city or county municipal well to provide water supply solely for residents of the city or county. I hereby certify that the information I have provided in this statement is accurate and truthful. Signed: — �� C4Z�� Date: Statement completed by: ;SWell Driller ❑ Well/Property Owner ❑ Other: 1868 E. Hazelton Avenue i Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com 1 nt-4