Laserfiche WebLink
SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows ho ,, <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: )014 c. s-+A...-t-e got-ci-e a, City: <br />Well Location APN: oeCi— 1`00-1-7 , <br />Applicant Name: C,./Ac+k_ vAtu br, If 1 ri cx Applicant Title: Deri <br />Applicant Address: CI p t.) (-y‹. t t-t-4 to City: M \ki.,cloan.-- <br />Applicant Phone: 9..041_)1 us , 0 t Applicant email: <br />Property Owner Name: Al-e(1 otrid r-\) CAsi--- 0 on <br />Property Owner Address:City: <br />Property Owner Phone:I—Ed— La (p— 1:;ef—(-0 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 />);er 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 />• <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 />• <br />A city or cwnty municipal well to provide water supply solely for residents of the city or county. <br />r\ I \ <br />• <br />I hereby certif la the information I have provided in this statement is accurate and truthful. <br />t474.% <br />Statement comp e e e , • <br />Signed: Date: <br />Well Driller Well/Property Owner 111 Other: <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com