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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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: LJ. mr,l-tiy-N <br />Well Location APN: D et 5- cH. 0 -- -7k, I <br />Applicant Name: po, h fc -04 c i- bri H ih 1), Applicant Title: DO t I --- { <br />Applicant Address: v).-, (A)... I L-1-1--I te.,7 City: p„. \i1,,,L r, <br />Applicant Phone: d,0 '1 , ci te f . Ss- 7 (.) Applicant email: <br />Property Owner Name: bk,A.; .G1 4) 1— I\Arti-6' I" e/t I <br />Property Owner Address: )._11. t pc, (, i ft c, 1 city: ,q-D <br />Property Owner Phone: "01.00 , 13), _ _ I t Property Owner email: <br />EXEMPTION CRITERIA <br />Well meets any of the following Exemptions: <br /> Well not located in a critically overdrafted basin. NI Tracy Subbasin (5-22.15) 1111 Cosumnes Subbasin (5-22.16) <br />Y <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 />• <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 />• <br />A city or county municipal well to provide water supply solely for residents of the city or county. • <br />I hereby certify that the information I have provided in this statement is accurate and truthful. <br />Signed: Date: <br /> <br />Statement completed: 0 Well Driller Well/Property Owner 0 Other: <br />1868 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com