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i reut.nt�5S <br />Environmental Health Department <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:1 <br />IF,999City: <br />M,vtW <br />oGt.l <br />Well Location APN: <br />— <br />2113 <br />Applicant Name: <br />ma <br />ApplicantTitle: <br />OW <br />Applicant Address:City: <br />�/ <br />Applicant Phone: <br />Applicant email: <br />Property Owner Name. <br />Property Owner Address: <br />City: <br />Property Owner Phone: <br />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 th <br />e law. In <br />V rder 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 <br />or county municipal well to provide water supply solely for residents of the city or county. <br />I herebv certifit_tha� t��,information I have provided in this statement is accurate and truthful. � <br />Statement <br />Well Driller ❑ WeI1lProperty Owner ❑Other: <br />Date: <br />1868 E. Hazelton Avenue ( Stockton, California 95205 I T 209 46$-3420 I F 209 464-0138 I www.sjcehd.com <br />