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U' 5KOAOUIN Environmental Health Department <br /> �1S COU NTY---- <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: " City: '" <br /> Well Location APN: <br /> Applicant Name: Applicant Title: g k r <br /> Applicant Address: City: <br /> Applicant Phone: Applicantemail: <br /> Property Owner Name: 7, cSh i <br /> PropertyOwner Address: City: <br /> Property Owner Phone: - Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> ❑ 1 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 /> 1771Replacement 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 /> 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 /> I hereby rtify that the information I have provided in this statement is accurate and truthful. <br /> Signed: 1 ��ArL�^ I Date: 1 l� <br /> Statement completed by: S Well Driller ❑ Well/Property Owner ❑ Other. <br /> 1868 E. Hazelton Avenue i Stockton,California 95205 1 T 209 468-34201 F 209 464-0138 1 www,sjcehd.com <br />