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f'° � c°�Z SAN�JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> `, <br /> COUNTY <br /> `, %/ Greatness grows here. <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: 'w d c'�4, <br /> Well Location APN:1 Z3o•- '0,6 <br /> Applicant Name: , �l Applicant Title:r_/ A/ <br /> Applicant Address: City: �/�q �� 4r 5 <br /> Applicant Phone: Ir 65.7 99M I Applicant email: ger lj, gi? <br /> Property Owner Name: 6A G, <br /> Property Owner Address: 2242glo 0 1 Lhija lel 4ef-190)'Aft-t City: o cw <br /> Property Owner Phone: D Property Owner email: <br /> EXEMPTION 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: ,.P5 Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: 7&Z—' <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 certify that the information I h provided in this statement is accurate and truthful. <br /> Signed: Date:� 4 / <br /> Statement completed by: AwellDriller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209468-34201 F 209464-0138 1 www.sjcehd.com <br />