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SAN jOAQUIN Environmental Health Department <br /> COUNTY— <br /> Greatness <br /> OUNTY— <br /> Greatn ss grows d»r_. <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 /> 4�EL1AOCAfION%fQD <br /> OWNEKTN <br /> N <br /> FQ�21A1[OIV �' � <br /> KrK�a, a k <br /> W1 i <br /> Well Location Address:,201 o2 h Ll t . City: 32C, <br /> Well Location APN: `1- --30 <br /> Applicant Name:, 1g.� �c�4✓i5 g. Applicant Title: p d <br /> Applicant Address: o, 253-70 <br /> Applicant Phone: / ,��� -�/ Applicant email:j���/,nq "&yll <br /> Property Owner Name: ak- <br /> Property Owner Address: 4/02 kj tilt, � <br /> Property Owner Phone: ('Lloq) 1414*_1610 Property Owner email; <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 substantially 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 certi hat the i formation I have provided in this statement is accurate and truthful. <br /> Signed: k�� Date: J2-h-7 <br /> 6 � <br /> Statement com letedb : 11` elliller ❑ 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 />