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2r-°„I Z Environmental Health Department° SAJOAQUlN <br /> ” Ute' ` —COUNTY <br /> Greatness grows here. <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 /> c3-P- <br /> R <br /> Well Location Address: City' w *f21 <br /> Well Location APN: - LkIO <br /> Applicant Name: YQIlev Applicant Title: <br /> Applicant Address: I City: L►V LVVMV4 0 <br /> Applicant Phone: - Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> �.+.�;a. �N�:' y,'�rt,'S� 1tr�tA/"Fl"f�� Y ,W�W' ja�,� ",lJ''i{.�1e4`.f13•-- <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 /> lk 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: 'k rve 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 /> ❑ 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 /> ❑ A city or county municipal well to provide water supply solely for residents of the city or county. <br /> I hereby cerffy#4the information I have provided i ement is accurate and truthfui�ll.7.--�� <br /> . Signed: Date: !iV <br /> Statement corn let by ell Driller ❑Well/Property Owner 17 Other: <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 4640138 1 www.sjcehd.com <br />