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SAN )Q A Q U I N Environmental Health Department COUNTY Well Exemption Statement Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption criteria must submit additional information prior to the issuance of a permit by the Environmental Health Department. This form must be completed to document the exemption criteria applicable for the new well application. WELL LOCATION AND OWNER INFORMATION Well Location Address: <_ City: 1 Well Location APN: 21 Applicant Name: Applicant Title: Applicant Address: I City: Applicant Phone: _-,� 1 Applicant email: �S�1N i th r�, i✓S tx k�� Property Owner Name: Property Owner Address: City: Property Owner Phone: 5 3cx� Property Owner email: EXEMPTION CRITERIA Well meets any of the following Exemptions: Well not located in a critically overdrafted basin. ❑ Tracy Subbasin (5-22.15) ❑ Cosumnes Subbasin(5-22.16) New well owner will be a de minimis extractor: maximum two acre-feet(351,702 gallons)or less per year being _ extracted for domestic ourooses onl\ Ponlaramont wall with camp Pytrartinn ac tho pvictinn wall that it is rpnlarinn Tr)mppt thic avmmntion the pxictinn `J wpll miict hp dpctrnvpri tinrlpr nprmit nr rnntinup to ha imprl fnr dompctir nrmnsPc with tntai rinmpstir.Pxtrartinns I ramainina two acre-feet or less per vear. i - I I Furpose/use OT existing well: u nerve an exisriny resiuence u irriydre resiuenudi idnusudpe I I New well estimatQd annual axtractinn vniuni { �nwuny rrcu coin nuicu uinivar cnu u,uvir vviuinc: i otal Annual Uomestic use volume: I I I Puhlic ananry that suh,.tantially meets nr Pxr:aarts thaw rannirpmants thrnunh annthpr rAmOrampnt of the law In I _ I order to be exempt.the applicant shall document the laws that substantially meet or exceed these reauirements I 7n/'1 nn\nr Tnr ranlll!L]mf]^tC n++n f!.•.^. i.,...-. .._,_... ._.._- Li m city or county municipal wen to proviae water suppry soieiy Tor restaents OT the city or county. j I 1 nereov cerary inat the imormauon I nave 1)rovlaea In tnls statement Is accurate ana irutntul, i I ,,._.__.__. ____._._._� �... I�i �nr..rrn.:u.,. f1 IA/,.IIID........fi.n..mn. n n�ti,.r• I 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 I F 209 464-0138 1 www.sjcehd.com