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, I <br /> R. "e Environmental Health Department <br /> COUNTY <br /> Well Exemption Statement <br /> Pursuant to Calffomis 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 /> WEU1MTM—AND OWNER INFoR1111AMN <br /> Well Location Address: 11,28 S S . W► ew <br /> Well Location APKI i q l- oy- oes <br /> Appikent Name:j rAar,76 S„ K-t S Applicant Title: 0,,.tie ' <br /> Applicant Address: City: TrACQ <br /> Applicant Phone: :!J92-- 1141 Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Mone:1 tProperty Owner email: <br /> EXEMMM 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: •Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: <br /> E)dsdng 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 cerffy that the information I have provided in this statement is accurate and truthful. <br /> Si ned: Date: <br /> Statement completed 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 />