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DocuSign Envelope ID:6E1EC6BA-6205-46D9-BCCB-8448F9459603 <br /> i . S A N J O A Q U I N Environmental Health Department <br /> 0: i N T Y <br /> `"t'(;`,'neS$ Chi,... <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: V-D City: +Q n <br /> Well Location APN: — <br /> Applicant Name: V1 Applicant Title: qtr <br /> Applicant Address: -b 9� I City: r) <br /> Applicant Phone: , 0 10 q Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: Sp ..f�v -., ,t City: 6t <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 /> ❑ 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 /> hereby ce6 if .th t the information I have provided in this statement is accurate and truthful. <br /> Signed: ,�bSt, u��ba 5/26/2023 <br /> Date: <br /> 259F177BDE22481... <br /> Statement completed by: ❑ 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 />