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1 ' <br /> SAN I GQ Q U I N 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: , 'r e-1 1c,V4 ' ti City: <br /> Well Location APN: <br /> Applicant Name: 'r0 ` rN_j Applicant Title: <br /> Applicant Address: q City: <br /> Applicant Phone: ,a c 1 3C_A _ 2-7-7j Applicant email: . Ile ,1 ,n S .I►c nC-i <br /> Property Owner Name: t,1) c ! <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> ❑ i 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 /> i remaining two acre-feet or less per year. <br /> f� Purpose/use of existing well: ❑ Serve an existing residence ❑ Irrigate residential landscape <br /> I 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 /> -Signed: � t 'l���� ! Date: 5 `1 <br /> Statement m leted by: ® Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E Hazelton Avenue ! Stockton, California 95205 1 7. 209 468-3120 1 F 209 464-0138 1 www.sjcehd.corn <br />