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SAN JOWIN <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 Location Address: City: <br />Well Location APN: /9j Q <br />Applicant Name:l <br />� Applicant Titfea <br />Applicant Address: S ufis� .�c/ City, <br />Applicant Phone: 9 97z - 275-7 Applicant email: <br />Property Owner Name: <br />Property Owner Address:City: ��,� <br />Property Owner Phone 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 />iNew <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 />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 />O i <br />A city or county municipal well to provide water supply solely for residents of the city or county, <br />I her certify that the inform i a 'rovided iq this statement is accurate and truthful. <br />Si ne . Date: <br />Statement corn feted b : Well Driller ❑ Well/Property Owner ❑ Other: <br />"853 E Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />OVA --1 <br />