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SAN J O A Q U I N (ILA 3-ironinental H c.,afth Deparbroen.t. <br /> c, j <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: �( oOC) City: G�1 <br /> Well Location APN: <br /> Applicant Name: vale f , 1 Applicant Title: , 11� <br /> Applicant Address: 9�? I City: La�A- <br /> Applicant Phone: c<I 3C-61 - 7-77 Applicant email: ,,t � r,11 i') L 5 )c <br /> Property Owner Name: G(_k f Ce ro <br /> Property Owner Address: 13 31 S 1 + 1 5 C.V-� U e�y city:'? Gk.A-c, <br /> Property Owner Phone: I 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 /> ❑ 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: <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 certify that the information I have provided in this statement is accurate and truthful. <br /> 17"Si ned: , � 'Gu a e~ Date: q �� <br /> Statement corn leled by: 01 Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton/avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />