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SAN , O A Q U I N 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: 3�, L _ -inc ;S c . IZ City: PccsM �� <br /> Well Location APN: <br /> Applicant Name: u Applicant Title: L-),- <br /> Applicant <br /> ;Applicant Address: I City: X0,1} <br /> Applicant Phone: 3. ccjJC_ c _ Applicant email: \,,11 e I ac ,t <br /> n c-�- <br /> Property Owner Name: <br /> Property Owner Address: So,'vn C. City: <<; <br /> Property Owner Phone: 2c c., -327— U5(. 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: �,_)e <br /> Existing well estimated annual extraction volume: <br /> Total Annual Domestic Use Volume: 4 Cru : CW <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 have provided in this statement is accurate and truthful. <br /> Signed: t s Date: I <br /> 9 ,� <br /> Statement completed by: 9 Well Driller ❑ Well/Property Owner ❑ Other: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />