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WP0042822
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042822
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Last modified
9/21/2022 1:19:17 PM
Creation date
9/21/2022 1:07:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042822
PE
4369
STREET_NUMBER
207
Direction
E
STREET_NAME
DURHAM FERRY
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
25527007
ENTERED_DATE
12/8/2021 12:00:00 AM
SITE_LOCATION
207 E DURHAM FERRY RD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
Tags
EHD - Public
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SANAOAQUIN <br />—COUNTY-- <br />Greatness <br />OUNTY-- <br />Greatness grows her <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: ao £. �,c >r <br />Well Location APN: <br />City: <br />j <br />extracted for domestic purposes only. i <br />Applicant Name: Q„k a _r,� <br />r �; Applicant Title: <br />well must be destroyed under permit or continue to be used for domestic purposes with total domestic extractions <br />Applicant Address: 3oc7 s . k. l fa fLaa <br />City: <br />Applicant Phone: as �, t, -j a <br />Applicant email: <br />CQ t. A-fi f I �I 16 <br />Existing well estimated annual extraction volume: <br />Property Owner Name: E (n r/ <br />LL..t✓ <br />Public agency that substantially meets or exceeds these requirements through another requirement of the law. In <br />Property Owner Address: ► I % <br />City: <br />Property Owner Phone: 2, 14s - Li5 -X15 <br />Property Owner email: <br />R: t,, ty1 <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br />Well not located in a critically overdrafted basin. l� Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin (5-22.16) <br />❑ <br />New well owner will be a de minimis extractor: maximum two acre-feet (651,702 gallons) or less per year being �I <br />extracted for domestic purposes only. i <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 />I herecertif that the information I have provided in this statement is accurate and truthful. <br />Signed: Date: ) a - I 3. <br />Statement completed by: 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 />,-�'A; ko <br />koo. t-1 <br />
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