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SAN-JOAQUIN <br />COUNTY -- <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 />93 <br />c d r ee K Ln <br />City:1 L ud i <br />Well Location APN: <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 />Applicant Name: <br />q �� <br />r >" ,,, c <br />Applicant Title:1 D <br />Applicant Address: <br />Existing well estimated annual extraction volume: , ��� i GOC) <br />Total Annual Domestic Use Volume: 3 G G G CG <br />Applicant Phone: <br />92 c S& <br />q_ -7 c <br />1 Applicant email 6 <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 />Property Owner Name: <br />Property Owner Address: <br />2 SS 3 <br />d rtc K <br />, r City: <br />L OcA, <br />Property Owner Phone: <br />I Property Owner email: <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br />❑ <br />Weil not located in a critically overdrafted basin. ❑ 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 <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 IZI Irrigate residential landscape <br />New well estimated annual extraction volume: 1 S C, I GCQ <br />Existing well estimated annual extraction volume: , ��� i GOC) <br />Total Annual Domestic Use Volume: 3 G G G CG <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 hereby certify that the information I have provided in this statement is accurate and truthful. <br />Si ned:7 22l.?�vDate: a <br />Statement completed by: Well Driller ❑ Well/Property Owner El <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />ylcb�,l <br />