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1 <br /> 1 <br /> SAN�IOAQUIN p <br /> Environmental Health Department <br /> f �( C OU NTY— <br /> Greatness grows fere_ <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 /> r x.."qY.. - .� • 'r' .p. 1 -x f V>y <br /> .� a..} yI:9L S''""`yp t R g b <br /> Well Location Address:h City <br /> Well Location APN: — I I U - <br /> Applicant Name: Applicant Title: <br /> Applicant Address: I City: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: _ City: <br /> Property Owner Phone: Property Owner email: <br /> S\ <br /> ,,d* r{,f.;' � i-41,t ry 9.�eY- '�iY7'Y nyytrC 9 L � Fm�,'F ,j'rstT;% Ile !«' <br /> e :�F"}_*r.;x`', i 'Y. "C+1, <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 permit or continue to be used for domestic purposes with total domestic extractions <br /> remaining two acre-feet or less per year. <br /> Purposeluse of existing well: Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: 'NM -FT <br /> Existin <br /> ?- <br /> Existing well estimated annual extraction volume: r` " <br /> Total Annual Domestic Use Volume: <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 requiireements 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 hereby cert at e i formation I have provided in this s to and truthful. <br /> Signed: I Date: 22 <br /> Statement co I AWell Driller ❑ Well/Property Owner ❑ Other. <br /> 1868 E. Hazefton Avenue I Stockton,California 95205 1 T 209 468-34201 F 209 4640138 1 www.sjcehd.com <br />