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anuiNSQ�� OQQVIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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: / ZSO AJ /01ar e 64eee 4e7l I City: Ae-v/,',,v tZyO <br /> Well Location APN: Sg- /y-e749 <br /> Applicant Name: %-zc Applicant Title: ,P,//,e/ <br /> Applicant Address: S k-h �vrLh / City: „"IGia LS'Z <br /> Applicant Phone: ZG g 7Z . 7 7 r7 Applicant email: ,gy4( n ll-,f&, ' !O <br /> Property Owner Name: <br /> Property Owner Address: 5 Z G�.c�iL City Z-ed,. yf-2 y0 <br /> Property Owner Phone: 11- y g5-- Tproperty 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 certify that the information I have pros' is statement is accurate and truthful. <br /> Signed: Date: 7- Z 7 - 2-o1Z <br /> Statement completed by: ❑ Well Driller ElWell/Property Owner ElOther: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />