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I <br /> DocuSign Envelope ID:OFD9CBCE-OBD9-467B-AB19-2DDD9165FEC6 <br /> �AN JOAQUIN Health Department <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 /> 44111 11 1­1114- 1.11___.....­.....­11_ 4 <br /> Well Location Address: Cit <br /> ,.00i6� <br /> -A <br /> Well Location APN:It ri 1111) 0_1 Lf <br /> Applicant Name: A <br /> tml�e_� Applicant Title:' <br /> .Applicant Address: <br /> .......... <br /> Applicant Phone `` Apj:licant email <br /> ............. ......... <br /> Property Owner Name: Y A, <br /> 'Y <br /> Property Owner Address:441 V2,,� 1-1 City: < <br /> F_- _ - I <br /> �ro�p Owner Phone: Owner email: <br /> EXEMPTION CRITERIA <br /> Well meets any of the following Exemptions: <br /> 0 Well not located in a critically overdrafted basin. 0 Tracy Subbasin(5-22.15) 0 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 /> El Replacement well with same extraction as the existing well that it is replacing.To meet this—exemption-the exisfing <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: 13 Serve an existing residence EJ 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 /> 171 A city or county municipal well to provide water supply solely for residents of the city or county. <br /> I hereby qLjfy,tgtjhe information I have <br /> .provided in this statement is accurate and truthful. <br /> Date: 1 2/8/2024 <br /> 1861)22245 ..L] <br /> Statement completed by: ❑ Well Driller. ?�.WeII/Proper 0 ity Owner Other., <br /> _. <br /> 1868 E Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 VPA"w siceho corn <br />