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WP0038214
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038214
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Entry Properties
Last modified
11/19/2024 4:01:49 PM
Creation date
1/27/2022 9:44:33 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038214
PE
4366
STREET_NUMBER
12077
Direction
E
STREET_NAME
STATE ROUTE 120
City
MANTECA
Zip
95336-
APN
20818010
ENTERED_DATE
5/4/2018 12:00:00 AM
SITE_LOCATION
12077 E HWY 120
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2018
Tags
EHD - Public
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SAN;IOAQUIN <br />t. < .. C O U N Y...._._. <br />Environmental Health Department <br />Well Exemption Statement <br />Pursuant to Califomia 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 />:.. <br />WEL[t.00ATION AND OWNER INI^ORMATION. <br />. .,._.. "._.... �. _. ....:. ::..... �=J.t'-2:i.Fe.,.� '.: .ti.tL:'�:1J55, �.:�fi ..... C..4...)t::::• �.�:. - <br />_..t .. .. .......... ....... .. .. ... ......................... J..... -.:tom:... ......... :s.. .. �... - !::f.:1f.'..:t:n<I: <br />Well Location Address:1 <br />12.011 E.. Ito <br />Cit : mAt-4TErA <br />Well Location APN:j <br />20S - gp - I o <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 />Applicant Name: <br />C PA AND KC. <br />Applicant Title: <br />Applicant Address: <br />Jda4. FSrA - <br />Ci q <br />Applicant Phone: <br />32 - <br />Applicant email: r <br />New well estimated annual extraction volume: <br />Existing well estimated annual extraction volume: <br />Property Owner Name: <br />tqPfeAQj W \-4EMVeLL_ <br />Property Owner Address: <br />p <br />city:1 <br />rV t3Pe5-rr_> <br />Property Owner Phone: <br />Zpq I <br />Property Owner email: <br />❑ <br />EXEMPTION CRITERIA ' �1�i txa' <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 />❑ <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 the law. In <br />❑ <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 ce f hat the irArmation I have provided in this statement is accurate and truthful. <br />Si ned:Date: 1 5 2- (� <br />Statement completed Well Dril r ❑ Well/Property Owner ❑ Other: <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />iM <br />
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