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SAN J OA Q U I N Environmental Health Department <br /> COUNTY <br /> Pursuant to California Water Code, well 1E3 p8 mptionew lls that Statement o not t the <br /> exemption riteriasubmit <br /> additional information prior to the issuance of a permit by the Environmental Health Departme tcThis formsmust be <br /> completed to document the exemption criteria applicable for the new well application. <br /> WELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: L53s2 ,v /1'!a <br /> Well Location AF UCity: '¢gym <br /> JJLI���oZ <br /> ------------ <br /> Applicant Name: Applicant Title., <br /> Applicant Address: <br /> city: <br /> Applicant Phone: Zo777 -z-7T­7 <br /> Property Owner Name: <br /> Property Owner Address: q_, ,v <br /> Property Owner Phone: 2 7yd <br /> 90 3p 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: ❑ Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: -6,7-1, 762, <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 /> 11 A city or county municipal well to provide water supply solely for residents of the city or county. <br /> 1 hereby certi that the information I hay rovided in this statement is accurate and truthful. <br /> Si ned: <br /> Statement corn leted b : Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />