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SA N ,J OAQ U IN 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' WAIN FIA City:! N <br /> Well Location APN: 22 - 13t)— 0-3�0 <br /> i <br /> Applicant Name:; I'1 N Applicant Titled WNW <br /> Applicant Address: Z3 0 City:, <br /> Applicant Phone: Applicant email:; <br /> Property Owner Name:' wv <br /> Property Owner Address:1 / City:j <br /> Property Owner Phone:j 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 /> Purposeiuse of existing well: Serve an existing residence ❑ Irrigate residential landscape <br /> New well estimated annual extraction volume: <br /> IIC, <br /> Existing well estimated annual extraction volume: p�- <br /> Total Annual Domestic Use Volume: YSS MAN <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 /> 1 hereby certifyAat the information I have provided in thi ent is accurate and truthful. <br /> Signed: Date: <br /> Statement c ted b 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 />