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_ <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />1-1F0. Greatness grows her ,. <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: / I ,29(), E ftto y 0, City: I001-0,--ci , Well Location APN: <br /> leAp <br />-7,OPPir6/9- <br />Applicant Name: ititotema ke kA -11-0)/cs Applicant Title: <br />Applicant Address: 5-9 J9-1) 0) 6/X 14(10/ City: <br />Applicant Phone:)-0.7q3/-a,)1() Applicant email: poprew,6v3a%17e:'• <br />Property Owner Name: /*II ALIZipki 1---Adj\v,{) <br />Property Owner Address: avio E a y City: <br />y <br />tvciod <br />Property Owner Phone: Property Owner email: <br />EXEMPTION CRITERIA . <br />Well meets any of the following Exemptions: <br />" <br />N 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: Serve an existing residence • Irrigate residential landscape <br />New well estimated annual extraction volume: ,it_A top_iii6/27-4- <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 />• <br />A city or county municipal well to provide water supply solely for residents of the city or county. • <br />A)a-' <br />that the information I have provided in this statement is accurate and truthful. <br />1LOI <br />I hereby <br />Signed: Vfl,i (11, <br /> <br />Date: <br />Statement completed by: 0 Well Driller 0 Well/Property Owner Other: ti4t0044 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com