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SKJOAOUIN Environmental Health Department <br /> --COUNTY---- <br /> Well <br /> --COUNTY---_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 pdor 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 /> r-- <br /> WELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: 5)3 G W U U :1 Lo d <br /> Well Location APN: - -7 <br /> Applicant Name: A 0-el Dr, )) , I Applicant Title: , ))� <br /> Applicant Address: &Y, 4a City: G ) I <br /> Applicant Phone: c,C 2—T7Applicant email: nljey c J} ,nj Ic ba <br /> Property Owner Name: q C , L 1_ <br /> ' Property Owner Address: G . SG City: <br /> Property Owner Phone: 9 qCP Property Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> ❑ Well not located in a critically overdrafted basin. 11 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 t <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: <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 /> hereby certify that the information I have provided in this statement is accurate and truthful. <br /> i <br /> Signed: <ti2?,Ux Date: <br /> Statement completed by: 3 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.sjcehd.com <br />