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SAN 10AQUIN Environmental Health Department <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: p S, Mvtol OM 1 city:1 MoKnw. <br /> Well Location APN:, i�1 — <br /> Applicant Name:jMRNIN GINNQ Applicant Title:i N$ft <br /> Applicant Address:;q I( City:; Icj7—ig <br /> Applicant Phone:'-201 911 Applicant email:' <br /> Property Owner Name: <br /> Property Owner Address: City:; <br /> Property Owner Phone:1 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: �K <br /> Serve an existing residence ElIrrigate residential landscape <br /> New well estimated annual extraction volume: 2- <br /> Existing well estimated annual extraction volume: L 6 "r <br /> Total Annual Domestic Use Volume: L Z a <br /> C 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 certifyVat the information I have pro In this statement is accurate and truthful. <br /> Signed: Date: I <br /> Statement com le ed by: Well Driller ❑ Well,Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton.California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />