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SANv3JOAQUIN <br />r' ------ CC) U N T Y----- - <br />'�. Off•. ��f C...i VSs 7f;j .Jj .'l E. -r, <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 />mylva 11110-7-11 =-LocationRNMIAtf:0r16Z <br />�.� ®r�� OTM� <br />Well •rtIIi�►��mtr���Property <br />New well owner will be a de minimis extractor maximum two acre-feet (651,702 gallons) or less per year being <br />❑ <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 />Owner Name: WIN a <br />Purposeluse of existing well: Serve an existing residence ElIrrigateresidential) landscape <br />New well estimated annual extraction volume:Existing well estimated annual extraction volumeTotal <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 />New well owner will be a de minimis extractor maximum two acre-feet (651,702 gallons) or less per year being <br />❑ <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 />Purposeluse of existing well: Serve an existing residence ElIrrigateresidential) landscape <br />New well estimated annual extraction volume:Existing well estimated annual extraction volumeTotal <br />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 />tE] <br />A city or county municipal well to provide water supply solely for residents of the city or county. <br />hereby oe ' at the information I have provided in this statement is to and truthful. <br />Si ned: I Date: <br />Statement ed by: N Well Driller ❑ WeIVProperty Owner ❑ Other. <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />