Laserfiche WebLink
N <br />c-\SAN JOAQUIN Q „ <br />(- COUNTY <br />-41 11FoP* (..)r eatness grows 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 />Environmental Health Department <br />WELL LOCATION AND OWNElyNFORMATION <br />Well Location Address: / 15/ BOtomebo Pc/ City lry446/1 &nip <br />Well Location APN: <br />Applicant Name: litcogynetns tthki t --file, Applicant Title: (3r' <br />Applicant Address:/0) 0,4260)( City: VeCietni <br />Applicant Phone: '-73/ -5(9 /() Applicant email: Alitengri5a..), <br />Property Owner Name: Lisa d Hera —117.46tex_ <br />Property Owner Address: po Bog' /144 53 City: 52ution,iii CA 6756/ <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 />• <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 />• <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: Date: <br />Statement completed by: 0 Well Driller 0 Well/Property Owner IA Other: <br />1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 www.sjcehd.com