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SOUTH SAN JOAQUIN GROUNDWATER SUSTAINABILITY AGENCY WELL DRILLING PERMIT APPLICATION ACKNOWLEDGEMENT FORM COMPLIANCE WITH EXECUTIVE ORDER N-7-22 19380 S. Jack Tone Rd. 245-020-27 PHYSICAL LOCATION (ADDRESS} APQN� By acknowledging the following, I S /<-� k. eH`A'Y'76 *ROPERTY OWNER or AUTHORIZED AGENT], understand that this form will be filed with the Secretary of the South San Joaquin Groundwater Sustainability Agency and forwarded to San Joaquin or Stanislaus County affirming that the proposed well is found to not be inconsistent with the adopted Eastern San Joaquin Groundwater Sustainability Plan. ROPERTY OWNER or AUTHORIZED AGENT Date f ACKNOWLEDGMENTS Pursuant to Executive Order N-7-22, the South San Joaquin Groundwater Sustainability Agency(SSJGSA) requires that the owner of a new well acknowledges the statements below in order for the SSJGSA to conclude that the new well would not be inconsistent with the existing Eastern San Joaquin Groundwater Sustainability Plan (GSP) as adopted by the SSJGSA Board of Directors. 1. 1 acknowledge that the Sustainable Groundwater Management Act requires that a groundwater sustainability agency(GSA) manage groundwater and that the location of my proposed new well is in the SSJGSA within the Eastern San Joaquin Subbasin. 2. 1 acknowledge that the SSJGSA has the authority to limit extractions within its jurisdiction including extractions from my new well if permitted by San Joaquin or Stanislaus County. 3. 1 acknowledge that a well drilling permit issued by San Joaquin or Stanislaus County does not guarantee the extraction of any specific amount of water now or in the future. 4. 1 acknowledge that the Eastern San Joaquin GSP includes specific groundwater requirements including adopted minimum thresholds and measurable objectives and that I am obligated to comply with these requirements. S. I acknowledge that the SSJGSA does not guarantee the maintenance of any defined groundwater level or minimum water quality in the Eastern San Joaquin Subbasin. 6. 1 acknowledge that the SSJGSA is not responsible for or otherwise liable for any costs, investments or payments related to my new well, if permitted or denied by San Joaquin or Stanislaus County, including pumping fees, extraction limits,costs related to well failure, well deepening, increased maintenance, replacement,or operational costs. 7. 1 agree to hold the SSJGSA harmless and indemnify the SSJGSA for any liability stemming from or related to the issuance of a well drilling permit or rendered land use decision by San Joaquin or Stanislaus County.