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DocuSign Envelope ID:B09CDE2E-6B76-4AAB-80AD-57B845AEE061 <br /> SA N J O A Q U I N Environmental Health Department <br /> CO NT`r <br /> Greatness crows 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: ( UobCity: <br /> Well Location APN: <br /> Applicant Name: 64!l;R C/ Wt (JV ► V1 Applicant Title: <br /> Applicant Address: 14L410 City: aW6" <br /> Applicant Phone: 6 Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: s <br /> Property Owner Phone: � C( — 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 /> IqNew 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 /> I hereby certi that the information I have provided in this statement is accurate and truthful. <br /> 10/2/2023 <br /> Signed: <br /> le alle th Date: <br /> F6ACDECEAEMig] <br /> Statement completed by: ❑ Well Driller Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www,sjcehd.com <br />