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F <br /> SA Nil MIN Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> OUNTY— <br /> Greatness grows Fere <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 /> .,M. m "�.�,t -r r,.y1.�;�Y'L �"s -��".r,�'d`✓se*rN�,?��v��� �;, -�,. roF'�. <br /> Well Location Address: <br /> Well Location APN ?j <br /> Applicant Name: Applicant True: N <br /> Applicant Address: �G till city: Ot(;- <br /> Applicant Phone:j I Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: I City: <br /> Property Owner Phone: Property Owner email: <br /> ­ <br /> Am"', <br /> f' 101, <br /> �`q 3 4'Y.15111­ <br /> MI 01"A <br /> x i v° Yi-�r N3. fx-x',73.1`h zlt�.1 i iiczyt <br /> One- '2}'2 `t �t J+ rFC(�t 3f`� �yf� � <br /> St <br /> h... s3 ✓'Y r. `k,c 'moi tas y a...v., C IQ. �`� t c� b i. w.?a <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: kerve an existing residence ❑ Irrigate rfir. <br /> esid tial landscape <br /> New well estimated annual extraction volume. G <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 ce ' t e in tion I have provid statement is accurate and truthful. <br /> Signed: Date: �2 <br /> Statement co"by: Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 4640138 1 www.sjcehd.com <br />