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` S A N 1 0 AU' ILI 1, �..����9r l�+l,��'�.��,�v��;�6��,.�fi�S 3 ��:.'e"d."r' w,+�.:� �..��.�P 3 <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: =\j r, , % City: L C,i i <br /> Well Location <br /> Applicant Name: n I Y� Applicant Title: D, *,I 1 C <br /> Applicant Address:-?—( kX-1 2 _ City: <br /> _ Applicant Phone:j a'c,(-k 3(-Q- : 77 ej �—^Applicant email:,qlkjdc It LI -o e4 <br /> Property Owner Name: S c"..Ac <br /> Property Owner Address: City: <br /> Property Owner Phone: �i`i ; X77- (� q 7 1 Property Owner email <br /> EXEMPTION CRITERIA <br /> t 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 /> Iremaining two acre-feet or less per year. <br /> l <br /> Purpose/use of existing well: ❑ Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: 5c;(, CCC. <br /> Existing well estimated annual extraction volume: , c ? <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 certify that the information I have provided in this statement is accurate and truthful. <br /> Signed: ` 0.11)ell Date: H <br /> Statement completed by: 9 Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjc<ehd.com <br />