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Engineering Services Department Land Development Engineering P.O. Box 642 Modesto, California 95354 [PHONE REDACTED] Modestogov.com APPLICATION TO INSTALL / ABANDON WATER, MONITORING OR EMERGENCYEXTRACTION WELL(S), OR ANY OTHER EXCAVATION(S) THAT MAY INTERSECT GROUNDWATER WITHIN THE CITY OF MODESTO. Location of Well No. of Wells or Type of Work: ☐New Well ☐Destruction Intended Use: ☐Agricultural ☐Irrigation ☐Industrial ☐Domestic (Private) ☐Domestic (Public)Cathodic Protection ☐ Geothermal ☐Dewatering ☐Other Estimated Water Usage Information: Landscaped area to be (sf or acres) Volume of lake or pond to be served (in gallon Applicant-Company: Mailing Address: Authorized Agent: E-mail: Telephone No: Consulting Firm: Mailing Address: Point of Contact: Telephone No: Contractor/Driller: Mailing Address: Point of Contact: Telephone No: C57 License ---PAGE BREAK--- The undersigned requests that the City of Modesto grant permission pursuant to attached Sections 5- 1.501 and 5-1.505 of the Modesto Municipal Code to install, construct, repair, modify, or destroy a water well, observation well, monitoring well, or any other excavation that may intersect groundwater in the City for any purpose whatsoever. The undersigned agrees to the following provisions: 1. The City retains the authority to deny a private well permit if it deems such a facility would present a detrimental impact to the aquifer below the City’s jurisdictional area or to the city’s ability to provide a safe, reliable and adequate water supply for the greater good of the service area. 2. The City is required to abide by the State’s Sustainable Groundwater Management Act and, as such, private wells will fall under the same requirements as the City’s public wells if it is determined that groundwater subbasin sustainability criteria as described in the Groundwater Sustainability Plans for which the City is a part are not being met. 3. The installation of the wells shall be subject to the supervision of the Director of Utilities of the City of Modesto and the Environmental Resources Department of the County of Stanislaus. 4. The installation shall be made in accordance with all requirements of the laws of the State of California, County of Stanislaus, and the City of Modesto. Installation shall meet all requirements set forth in the latest revision of the State Department of Water Resources Bulletin 74-81, Water Well Standards: State of California and supplement No. 74-90, California Well Standards: Water Wells, Monitoring Wells, Cathodic Protection Wells. Well- head locks are required on all Wells. A copy of the Well Driller’s Log must be submitted to the City per direction of City staff within 30 days of drilling the well. 5. When the wells are no longer required, the undersigned shall abandon and permanently seal them in accordance with the requirements of the Director of Utilities. The undersigned agrees at its sole cost and expense, in accordance with applicable laws, to permanently and effectively abandon any well(s) that it has installed thereon according to the latest revision of the State Department of Water Resources Bulletin 74-81 and 74-90. Said abandonment shall be done to the reasonable satisfaction of the City of Modesto’s Director of Utilities or his authorized representative. ---PAGE BREAK--- 6. In the event that the undersigned fails to vacate and abandon the well(s) when no longer required, then the City of Modesto, or its authorized agents, may enter upon the premises and abandon the well(s) in accordance with paragraph 3. In such case, the undersigned agrees to reimburse the City of Modesto for any and all reasonable expenses it may so incur and waive any and all claims for damages against the City of Modesto, its agents or employees. 7. All construction, repair, modification, destruction, or abandonment of permitted wells shall be subject to the supervision of the CITY and the Environmental Resources Department of Stanislaus County. 8. The undersigned agrees that the permission granted hereby will be binding on all of its successor’s, assigns and heirs. 9. If a City of Modesto water connection exists on the premises, the City of Modesto Cross Connection Specialist must be contacted in order to do the initial inspection at (209) 342-2207. A USC approved backflow assembly may be required for Cross Connection protection as per City Standard. The newly installed approved backflow assembly must be tested by the Cross- Connection Specialist in order to expedite the permit process. 10.A permitted well is only allowed for the use as specified this permit application. A new permit is required for a change in use of a permitted well. 11.All water conservation restrictions including watering curtailments enacted by the City Council or as delegated by City Council to City Departments shall be followed by private well owners. 12.Private wells are required to provide a reliable means to measure the amount of water being extracted which might include a meter. The water usage data is required to be submitted to the City on a regular basis. A water meter would be a non-billed account for the purposes of tracking water usage only. The applicant is required to coordinate with the Water Division on the appropriate mechanism for collection of the water meter data. ---PAGE BREAK--- Please Note: 1. Actual construction, repair, modification, destruction, or abandonment cannot begin until the Stanislaus County Department of Environmental Resources has reviewed and approved the initial work plan. Any well information generated, as a result of this effort, shall be released to the CITY OF MODESTO and/or the Department of Environmental Resources. 2. Permission to install monitoring test well(s) and/or Emergency extraction well(s) on the above referred to property located in the City of Modesto, in accordance with the provisions of Section 5, Article 5, Construction, Operations, and Maintenance of Wells and subject to the above Name of Company conditions. 3. In addition, actual installation/abandonment cannot begin until the issuance of a permit by the City of Modesto that may require approval by the County Department of Environmental Resources. I/We agree to the above: Name of Authorized Agent Signature of Authorized Agent Date Title of Authorized Agent SIGN ---PAGE BREAK--- For Staff Use: County approval required: ☐ Yes☐ No Stanislaus County Department of Environmental Resources signifies by the signature below that it has received and reviewed the initial work plan proposal. Land Development Engineering Date Stanislaus County Department of Environmental Resources Division of Hazardous Materials City Engineer Date Director of Utilities Date In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at SIGN SIGN SIGN SIGN