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I hereby c <br />Signed: <br />that the infor <br />Statement complete El Well Driller LI Well/Property Owner Other: <br />tion I Ilay_e_g_Dvided in this statement is accurate and truthful. <br />"gii/441.,2M. L 9 .9r Date: <br />Environmental Health Department <br />COUNTY <br />r- loSma Greatness 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 />WELL LOCATION AND OWNER INFORMATION <br />'1-1;06--wi Well Location Address: L-530/ c3Aprobje_ City: <br />Well Location APN: <br />I 6, thil,99eg., Applicant Name: kitoparyukt:5 1.0,15:51-rryis Applicant Title: <br />Applicant Address.,Qtao toile,9< 1 ad City: —440 <br />Applicant Phone: gol -GIN _ 0 Applicant email: iviciyhivap ie,S4 <br />ci Lattytt .R.,ifIrrui3O Property Owner NamejeizAA <br />Property Owner Address: e...L_G•3 c4.pitau2_e_ City: 5f0C42tiotep,- <br />Property Owner Phone: acCi... WA- SCCV Property Owner email: <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br />• Well not located in a critically overdrafted basin. Li Tracy Subbasin (5-22.15) II Cosumnes Subbasin (5-22.16) <br />n 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 Li 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. E <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com