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S A N 10A Q U I N Environmental Health Department <br /> —COUNTY <br /> Greatness grows t, <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: p City: S.�.a <br /> Well Location APN: _p -O O <br /> Applicant Name: :, otclAern I Applicant Title: L%jn(- <br /> Applicant Address: kSsD 2rw�t1 410e. City: SIL4 <br /> Applicant Phone: - 2-0 11.0 Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: <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: XSefve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: IeSs 4A--k 2.ftrce (�e4-i- <br /> Existing well estimated annual extraction volume: r + r <br /> Total Annual Domestic Use Volume: t <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 hereb certi that the information I have provided in this statement is accurate and truthful. <br /> Si ned: —� Date: <br /> Statement completed by: ( KWell Driller ❑Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />