Laserfiche WebLink
SA N J OAQ U I N Environmental 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 /> Well Location Address:) �m 1 f WMPS City:; 9ba loN <br /> Well Location APN: - - 2 <br /> _ _Applicant Name:' lurvul C-24[11)NILI Applicant Title:' <br /> Applicant Address:; m Qjk � C <br /> ity: i7 n <br /> Applicant Phone: Z 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) ❑ Cos umnes 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: _ <br /> Existing well estimated annual extraction volume:Total Annual Domestic Use Volume: 4AMPI—Auff <br /> ❑ Pubiic 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 /> hehe certify-that t e informa LiWKave provided in this statement is accurate and truthful. <br /> Signed: <br /> Date: <br /> Statement led b : W II Driller ❑ Well/Property Owner ElOther: <br /> .] <br /> 'good E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwvw.s}cehd.corr <br />