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SAN JOAQUIN <br />COUNTY <br />r� r,' Greatness grows f, <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 meets any of the following Exemptions: <br />❑ <br />Well Location Address: <br />';� <br />, pcj) - I c, p <br />City: <br />_ C 0 <br />Well Location APN: <br />Q'_3 <br />- d 70 15 <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 />Applicant Name: c, <br />Applicant Title: <br />hr , -e �^ <br />Applicant Address: <br />❑ <br />City: <br />v ; <br />Applicant Phone: 9 (,) q <br />3(2-, c - R -7 7 c <br />Applicant email <br />\j�; I iry ci r, J� .,5 CU S Uc <br />A city or county municipal well to provide water supply solely for residents of the city or county. <br />Property Owner Name: K <br />S <br />Property Owner Address: -7C,-7 <br />SU"' I_ca V- c S 1 <br />City: <br />Property Owner Phone: <br />- <br />Property Owner email: <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br />❑ <br />Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin (5-22.16) <br />fA <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 />❑ <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 />❑ <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: ® Well Driller ❑ Well/Property Owner ❑ Other: <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T. 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />V1 e j- <br />