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SANMIN Environmental Health Department <br /> COUNTY-- <br /> Greotness 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 /> Well Location Address: Cfty:1 MW <br /> Well Location APN: — <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 /> yet» �r_a tFY YW ', <br /> RN, <br /> .: bx. <br /> ._ `�a.. 'a' �,.e`dx <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 exb'actor 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 ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: ift a fl-- <br /> Existing well estimated annual extraction volume: <br /> Total Annual Domestic Use Volume: <br /> El 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 certify thintion I have provided in this sta accurate and truthful. <br /> . Signed: /Ar%1!M <br /> Date: <br /> Statement corn b : ell Driller ❑ Welt/Property Owner O Other <br /> 1868 E. Hazelton Avenue I Stockton,Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />