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r <br />ro <br />°° °Z SAKJOAQUIN <br />11 U, <br />`COUNTY <br />\'.c14. P Greotness grows here. <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 />Well Location Address: <br />Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin (5-22.16) <br />City: <br />Well Location APN: <br />-- <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 />Applicant Name: <br />Applicant Title: �i✓ <br />Applicant Address: D )p <br />City: ✓-) <br />Applicant Phone: Oa e( (p <br />Applicant email: <br />New well estimated annual extraction volume: <br />Property Owner Name: <br />Existing well estimated annual extraction volume: <br />Property Owner Address: k J <br />City: <br />❑ <br />Property Owner Phone: — 0 <br />Property Owner email: <br />order to be exempt, the applicant shall document the laws that substantially meet or exceed these requirements <br />J - <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 />_j�cNew <br />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 />hereby certifyftthe information I have provided in this statement is accurate and truthful. <br />Signed: Date: �--� <br />Statement competed by: Well Driller ❑ Well/Property Owner ElOther: <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />