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DocuSign Envelope ID:C793664A-E4B3-4B47-BF38-799E265783B6 <br /> SAN JOAQUIN EnvironmentalHealth Department <br /> ,qtness grows � <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 /> Well Location Address: City: <br /> Well Location APN: <br /> Applicant Name: Vt Applicant Title: V'\ -P—Yi <br /> Applicant Address: D {l City: c. tet.-✓ V1 Ic-, <br /> Applicant Phone: 0 ,0l D Applicant email: <br /> Property Owner Name: 0 <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 /> ❑ 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 /> 2r 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: WServe an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: _1-eSS � OCAV-� 200, ' <br /> Existing well estimated annual extraction volume: <br /> Total Annual Domestic Use Volume: .72— <br /> F1 <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 /> hereby certi tat he information I have provided in this statement is accurate and truthful. <br /> 18/16/2023 <br /> Signed: h Date: <br /> 14F6B73E921E47 . <br /> Statement completed by: ❑ Well Driller ell/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />