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SAKJOAQUIN Environmental Health Department <br /> COUNTY-- <br /> \�� r-eotness 9,;,:; <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: i y to N, eu, S'( City: <br /> Well Location APN: `>-Ied 1 oo0 <br /> Applicant Name: �C-;1 Applicant Title. <br /> Applicant Address: -joo S. City: <br /> Applicant Phone:j ;)-acl 616 --7D-_ I Applicant email: COJ"'OL 'r 1 c tr^.".(, <br /> Property Owner Name: Srt/rjrN, 1 C, <br /> Property Owner Address: S G, ar.t or. 1. 'a. o 1 City: <br /> Property Owner Phone: - 7 - oro Property Owner email: •f o, PjTa _ <br /> 6-"'1 A e.r . C'0 rs� <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 the law. In <br /> order to be exempt,the applicant shall document the laws that substaptially meet or exceed these requirements <br /> and how the requirements of those laws were met. <br /> ❑ A city or county municipal well to provide water supply solely for residents of the city or county. <br /> I hereby certify tW the information I have provided in this statement is accurate and truthful. <br /> Signed: 1 1 Date: a- <br /> Statement corn leted by: L`D Well Driller ❑ 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 />