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I hereby That rmation I have provided in 's statement is accurate and truthful. <br />Date: ()- <br />Statement co pleted by: _ Ikell Driller 0 Well/Property Owner 0 Other: <br />Signed: <br /> <br />c;,butA, SAN)JOAQUIN <br />COUNTY <br />r. <br />:14 'g0C,14\ 1...)reatiVISS grows ilerE <br /> <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: BUNN <br />Well Location APN: <br />2.010 /11#12tc Pk- City: <br />2...o - 040- 00 <br />Applicant Name: MAIN 4-1),* rnala.i0./ Applicant Trtle: OVJ N-02 <br />Applicant Address: 2.01V10 utywkiart pot• City: acci I ON <br />Applicant Phone: 2,oct • gl g • g348' Applicant email: <br />Property Owner Name: SAME' <br />Property Owner Address: City: <br />Property Owner Phone: Property Owner email: <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br />(5-22.15) 0 Cosumnes Subbasin (5-22.16) II Well not located in a critically overdrafted basin. • Tracy Subbasin <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 />Nti 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: vss-fitiN 2 46 Pt-- <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 />III <br />A city or county municipal well to provide water supply solely for residents of the city or county. • <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com