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S A N,10 A O U l N Environmental Health Department <br /> J <br /> —COUNTY— <br /> Greatness <br /> COUNTY—•— <br /> Greatness grows here <br /> Well Exemption Statement <br /> Pursuant to Caldomia 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 Address: <br /> Well Location APN 7j <br /> Applicant Name: tAA Applicant Title: <br /> Applicant Address: G city: MQW 0P <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone; - ProDertv Owner email: <br /> .;F�' ;, ^ + y� `�1F11"'S' <br /> •�JJ 3 ajA`•ya ''�' pN 2Y}fcF'7 +�t"�Lv y' i3�' any + F , +.G Mr c K a <br /> i4t!a 1 ../ =Y •.:. <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 /> ❑ 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 perrnit 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 weN: [Serve an existing residence [IIrrigate resTF <br /> l landscape <br /> New well estimated annual extraction volume: G <br /> Existing well estimated annual extraction volume: '' n <br /> Total Annual Domestic Use Volume: <br /> L1 Public agency that substantially meets or exceeds these requirements through another requirement of the law.In <br /> order to be exempt,the appficent shalt document the taws that substantially meet or exceed these requirements <br /> and how the requirements of those laws were met. <br /> ❑ A city or county municipal well to provide water supply solely for residents of the city or county. <br /> I herebyce t in tion I have pro statement is accurate and truthful. <br /> Signed- Date: I g �2 <br /> Statement ed by: Well Driller ❑ Well/Property Owner ❑ Other. <br /> 1868 E. Hazefton Avenue I Stockton,Cakfomia 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />