Laserfiche WebLink
J(WNuJ�I» W�F�k'::,-7 ' <br /> S A N.10 A Q U I N Environmental Health Department <br /> ---- -COUNTY — <br /> Well Exemption Statement <br /> Pursuant to California Water Code, Section 13808, all new welts 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 Q City: rho 0Q_%32t <br /> Well Location APN: <br /> Applicant Name: n Applicant Title: <br /> Applicant Address: I City: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: 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 /> P <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 /> Purposeluse of existing well: XServe an existing.residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: AG <br /> Existing well estimated annual extraction volume: k 1 <br /> Total Annual Domestic Use Volume: t'y I t <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 Gerfify that the ipfogrnoon I have provided in this statement is accurate and truthful. <br /> Si ned: �6� Date: <br /> Statement completed by: Well Driller ❑ Wel weer ❑ Other: <br /> 1568 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www,sjcehd.com <br />