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= S A N X10 A Q U I N Environmental Health Department <br /> ---COUNTY—- <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 /> We <br /> Well Location Address: C <br /> Well Location APN: <br /> Applicant Name: Applicant Title: <br /> Applicant Address- Nim City: <br /> Applicant Phone: ,2 — _f; 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 /> F1 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: %berve an existing.residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: 2AG <br /> Existing well estimated annual extraction volume: - C� <br /> Total Annual Domestic Use Volume: lk 11 <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 /> DTA or county municipal well to provide water supply solely for residents of the city or county. <br /> 1 hereby certify that the inforrpation 1 have provided in this statement is accurateandtruthful. <br /> Signed: T-A/ R' Date: U� <br /> Statement completed b : I L&Well Driller ❑ Well/Property Owner O 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 />