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S A N 10 A 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: ;=, . -_-:4 ;S � I City] + <br /> Well Location APN: !1153Z l C10°)0000 <br /> Applicant Name: {-�G!� siN,z �f'tiG':� ;►lC, Applicant Title: ;!E v <br /> Applicant Address: ttpZ4 ('arw ho !r1 . City: N fir?. <br /> Applicant Phone: 0 3']CF L _ Applicant email: ww. i he �►taA 1. <br /> Property Owner Name: k,6 I rv--txt) <br /> Property Owner Address: , ➢v7A. S City: S <br /> Property Owner Phone: .uvv,.P, (ZLA)33? 17 Property Owner email: ' iixmr".t(�6qi n {• <br /> I <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: K 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 ceqify that,the information I have provided in this statement is accurate and truthful. <br /> signed: Date: ; �,l 26 i-v <br /> Statement com leted by: .Well 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 />