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1. Location of Well Site: No. of Wells or Borings: 2. Applicant-Company: Mailing Address: Telephone No: Authorized 3. Consulting Firm: Mailing Address: Telephone No: Point of Contact: 4. Contractor/Driller: Mailing Address: Telephone Number: Point of C57 License Number: The undersigned requests that the City of Modesto grant permission pursuant to 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: 5. 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. 6. 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. 7. 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. 8. 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. APPLICATION TO INSTALL / ABANDON WATER, MONITORING OR EMERGENCYEXTRACTION WELL(S), OR ANY OTHER EXCAVATION(S) THAT MAY INTERSECT GROUNDWATER WITHIN THE CITY OF MODESTO. Revised 4/15/16 1 ---PAGE BREAK--- 9. 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. 10. The undersigned agrees that the permission granted hereby will be binding on all of its successor’s, assigns and heirs. 11. 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. Stanislaus County Department of Environmental Resources signifies by the signature below that it has received and reviewed the initial work plan proposal. Stanislaus County Department of Environmental Resources Division of Hazardous Materials Please Note: 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 the Department of Environmental Resources. Permission to install monitoring test well(s) and/or I/We agree to the above: 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 Name of Authorized Agent above Name of Company conditions. In addition, actual installation/abandonment cannot begin until the County Department of Environmental Resources has also approved the project. Signature of Authorized Agent Title of Authorized Agent Date Director of Utilities Date Revised 4/15/16 2 ---PAGE BREAK--- MINIMUM WORK PLAN REQUIREMENTS In addition to the attached application and any other information required during the permit process, Section 5-1.505 of the Modesto Municipal Code requires the following for all permit applications. Submit one original and two copies of the application with three copies of the work plan and any attachments or drawings. Please check the box to indicate the item is attached to or included with the permit application. A copy of the plot plan indicating the exact location of the well or boring with respect to the following features within a radius of five hundred (500) feet of the well or boring. Approximate property lines. All sewage disposal systems or works carrying or containing sewage or storm runoff. All intermittent, perennial, natural, or artificial water bodies or watercourses. Drainage pattern of the property. All existing wells of all types, regardless of whether they are subject to regulation under this article. All access roads, and All subsurface utilities. Location of property, including street address, township/range/quarter section, or other information sufficient to identify the well site location. Name and address of the person who will perform the work on the well or boring Name and credentials affiliation of inspector. Proposed depth of well/boring. Proposed use of well/boring. Proof satisfactory to the Director that the person who will construct, modify or abandon the well or boring(s) possesses a valid license to perform such work, which has been issued in accordance with the California Contractors License Law (Chapter 9 of Division 3 of the Business and Professions Code, Sections 7000-7173). A certificate satisfying the requirements of the California Workers Code (Sections 3800 et seq). Compensation and Insurance Law (Part 1 of Division 4 of the Labor Code, Sections 3200- 4418). (Certificate of Insurance for Workers Comp.) Copy of a valid City of Modesto Business License for both Consultant and Contractor. Such fee as the Council may from time to time impose. The required fee shall accompany the Application and shall be nonrefundable. Upon approval of the work plan, the fee(s) will be collected for each well or excavation installed before the permit will be issued. Such other information as the Director of Utilities may deem necessary to determine whether underground waters meet minimum protection standards as set below. Revised 4/15/16 3 ---PAGE BREAK--- Article 5 Construction, Operations, and Maintenance of Wells 5-1.501 Permit Necessary. It shall be unlawful 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 without first securing a valid permit. (Added by Ord. 2703-C.S., § 1, effective 3-15-90) 5-1.502 No Water Shall Be Returned to Wells. No person shall permit any water to be returned to wells; provided, however, the Health Officer may grant permission for such return, subject to necessary conditions to protect the public health and safety. (Added by Ord. 2703-C.S., § 1, effective 3-15-90) 5-1.503 Definitions. “Abandoned well” means a well that has not been used for a period of one year, unless the owner or person in lawful possession of the well demonstrates his/her intention to use the well again for supplying water or other associated purpose (such as an observation well). The well shall then be considered “inactive.” As evidence of his/her intentions for continued use, the owner shall properly maintain the well in such a way that: The well has no defects which will allow the impairment of quality of water in the well or in the water- bearing formations penetrated. The well is covered such that the cover is watertight and cannot be removed except with the aid of equipment or the use of tools. The well is marked so that it can be clearly seen. The area surrounding the well is kept clear of brush or debris. If the pump has been removed for repair or replacement, the well shall not be considered “abandoned.” During the repair period, the well shall be adequately covered to prevent injury to people and to prevent the entrance of undesirable water or foreign matter. Observation or test wells used in the investigation or management of groundwater basins by governmental agencies or engineering or research organizations are not considered “abandoned” so long as they are maintained for this purpose. However, such wells shall be covered with an appropriate cap, bearing the label, “Observation well,” and the name of the agency or organization, and shall be secured and locked when measurements are not being made. When these wells are no longer used for this purpose or for supplying water, they shall be considered “abandoned.” “Cathodic protection well” means any artificial excavation by any method for the purpose of installing equipment or facilities for the electrical protection of metallic equipment in contact with the ground. “Code” means the Municipal Code of the City of Modesto. “Department” means the Public Works Department of the City of Modesto. “Director” means the Public Works Director of the City of Modesto or their duly authorized representative. “Monitoring well” means any well used exclusively for monitoring or sampling conditions of a water-bearing aquifer, e.g., water pressure, depth, movement, or quality. “Exploratory boring” means an uncased excavation used to determine the engineering or geological properties of subsurface materials by seismic investigation, direct observation or any other means. (Added by Ord. 2703-C.S., § 1, amended during 11-98 supplement and by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.504 Permit. The Public Works Director is authorized to issue a permit to install, construct, repair, modify or destroy a water well, observation well, monitoring well, emergency extraction well, or any other excavation that may intersect groundwater in the City for any purpose whatsoever. A nonrefundable fee shall be paid upon application for the permit in an amount as approved from time to time by resolution of the City Council. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) Revised 4/15/16 4 ---PAGE BREAK--- 5-1.505 Permit Application. Applications for permits shall be made to the Public Works Director, on forms supplied by the Public Works Director, and shall include the following: A plot plan indicating the exact location of the well with respect to the following features within a radius of five hundred (500) feet of the well: Approximate property lines, All sewage disposal systems or works carrying or containing sewage or storm water runoff, All intermittent, perennial, natural, or artificial water bodies or water courses, Drainage pattern of the property, All existing wells of all types, regardless of whether they are subject to regulation under this article, All access roads, and All subsurface utilities; Location of property, including street address, township/range/quarter section, or other information sufficient to identify the well site location; Name and address of the person who will perform the work on the well; Name and credentials affiliation of inspector; Proposed depth of well; Proposed use of well; Proof satisfactory to the Public Works Director that the person who will construct, modify or abandon the well or boring(s) possesses a valid license to perform such work which has been issued in accordance with the California Contractors License Law (Chapter 9 of Division 3 of the Business and Professions Code, Sections 7000-7173); A certificate satisfying the requirements of the California Workers Code (Sections 3800 et seq.). Compensation and Insurance Law (Part 1 of Division 4 of the Labor Code Sections 3200-4418); Such fee as Council may from time to time impose. The required fee shall accompany the application and shall be nonrefundable; Such other information as the Public Works Director may deem necessary to determine whether underground waters meet minimum protection standards as set below. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.506 Permit Issuance. Prior to the issuance of a permit, if the Public Works Director so requires, an applicant shall deposit with the City Clerk a security instrument, in a form acceptable to the City Attorney and in an amount deemed necessary by the Public Works Director to insure proper and complete performance of permitted work. The security amount shall not exceed one hundred (100) percent of the total estimated cost of the permitted work. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.507 Permit Validity. Issuance of a permit under this article to any person does not entitle the holder thereof to carry on any work or business thereunder unless permittee has fully complied with all the applicable requirements of this Code and all other applicable Federal, State, or local provisions of the law. (Added by Ord. 2703-C.S., § 1, effective 3-15-90) 5-1.508 License Required of Persons Performing Permitted Work. No person shall perform any work, either on such person’s own property or on the property of another, for which a permit is required by this article unless such person is in possession of a valid license appropriate to such work which has been issued in accordance with the California Contractors License Law (Chapter 9 of Division 3 of the California Business and Professions Code, Sections 7000--7173). Licensed water well contractors (Class C-57) may perform all types of permitted work, while licensed engineering contractors Revised 4/15/16 5 ---PAGE BREAK--- (Class A) and limited specialty contractors (Class C-61) may perform only permitted work on engineering test holes. (Added by Ord. 2703-C.S., § 1, effective 3-15-90) 5-1.509 Permit Term. A permit shall expire six months after the date of issuance. Permits for exploratory boring shall expire thirty (30) days after the date of issuance. The permittee shall complete all work authorized by a permit and satisfy all the requirements of the permit prior to its expiration. (Added by Ord. 2703-C.S., § 1, effective 3-15- 90) 5-1.510 Extension of Permit Term. The Public Works Director may grant one or more extensions of a permit, each for a period not exceeding three months, if the permittee demonstrates to the satisfaction of the Public Works Director that circumstances beyond the permittee’s control prevented completion of the permitted work prior to permit expiration. Any such extension granted may be subject to such conditions as the Public Works Director may deem necessary, including but not limited to a cash deposit, security bond, or other security instrument to insure proper and complete performance of the permitted work. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.511 Permit Denial or Revocation. Whenever it appears to the Public Works Director that an application should be denied under the standards herein, or that a permittee is in violation of any of the provisions of the permit, this Code, or any applicable federal, state, or local provisions of law, he/she shall have the authority to deny the application or to summarily suspend the permit. The suspension order shall also constitute notice of proposed revocation. Written notice of such proposed revocation shall be given by depositing in the United States mail a notice directed to said permittee at the address given in the application. The notice shall set forth the reasons for the proposed revocation and shall notify the permittee that he/she has ten (10) days in which to file a written request for a hearing before the Public Works Director. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.512 Notice and Review of Denial or Revocation. The applicant or permittee shall be notified in writing that applicant or permittee shall have ten (10) days from the date of such notice to request in writing a hearing before the Public Works Director or his/her designee to appeal denial of the permit application or to determine if the permit should be revoked. If the applicant or permittee fails or declines to make any such timely request, such omission shall be deemed a waiver of the applicant’s or permittee’s rights to be heard on the pending matter, and the application will be deemed denied or the permit may be revoked. In case of an application denial, or a summary suspension or notice of revocation, the Public Works Director shall provide a hearing within fifteen (15) days after receipt of a written request from the permittee, at which hearing the permittee may present oral or written evidence why the application should be granted or why the permit should not be revoked. Notice of the time and place of such hearing shall be given to the applicant or permittee by deposit of the notice in the United States mail at least ten (10) days before the hearing to the address given in the application. If the application is denied or the permit is revoked, written notice shall be given to the applicant or permittee within twenty-five (25) days of the close of the hearing. Notice shall be given by United States mail. The permittee will be presumed to have received said notice within five days after mailing. It shall be unlawful for any person whose application is denied or whose permit is revoked under this action to construct, operate, or maintain any well within the City. Any person who does so without a permit is guilty of an infraction and subject to criminal prosecution and/or civil litigation as provided in this Code. No person whose permit is denied or revoked may apply for a permit to construct, operate, or maintain any well in the City of Modesto for a period of three months from the date of such denial or revocation. Revised 4/15/16 6 ---PAGE BREAK--- Any person whose application is denied or whose permit is revoked under this article shall have the right, after receiving notice in writing of the denial or revocation, to file a written appeal to the City Council pursuant to the provisions of Chapter 4 of Title 1 of this Code. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129- C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.513 Standards: Adoption by Reference. Standards for the construction, repair, modification, abandonment, or destruction of well so as to protect groundwater from contamination and pollution and to preserve health, safety, and welfare shall be those set forth in the California Department of Water Resources Bulletin No. 74-81 dated December 1981 and entitled Water Well Standards: State of California as supplemented by California Department of Water Resources Bulletin No. 74-90 (Supplement to Bulletin 74-81), dated January 1990 and entitled California Well Standards: Water Wells, Monitoring Wells, Cathodic Protection Wells, together with all appendices thereto, as compiled and published by the Department of Water Resources of the Resources Agency of the State of California. These certain documents, three copies of which are on file in the office of the City Clerk of the City of Modesto, as hereinafter amended, deleted, modified and added to, and the same are hereby adopted by this reference as the Groundwater Conservation Code of the City of Modesto, with the following additions: Every new, repaired, or modified community water supply well or individual domestic water well, after construction, modification, or repair and before being placed into service, shall be thoroughly cleaned of all foreign substance and shall be thoroughly disinfected utilizing the procedures set forth in Appendix C of the aforementioned Bulletin No. 74-81. Exploratory boring deeper than ten (10) feet shall be destroyed immediately upon completion of testing by complete filling and/or sealing of the borehole in accordance with criteria established by the Public Works Director. The Public Works Director may waive complete sealing if the permittee demonstrates to the Public Works Director’s satisfaction that City’s groundwater protection and conservation shall not be impaired by the permittee’s proposed methods. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.514 Well Logs. Any person who has performed any work for which a permit is required hereunder and which involves drilling, digging, excavating or boring of a well, or exploratory boring, shall, within thirty (30) days following completion of such work, submit to the Department an accurate and complete well log on forms satisfactory to the Public Works Director (DWR 188 [latest revision]). In areas for which the Public Works Director deems the available subsurface information insufficient, the permit may require any person performing a completion operation to submit a well log prior to commencement of the completion operation. Well logs shall include all of the following: A detailed record of the boundaries, character, size, distribution and color of all lithologic units penetrated; The specifications and approvals for well casing; The location of perforations filter pack and sealing zones; Reports on the quantity and quality of groundwater (if available); and Any other data required by the Public Works Director in the permit conditions. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.515 Inspection. The Public Works Director and City inspectors may, at any and all reasonable times, enter any and all places, property, premises, enclosures, and structures for the purpose of making examinations and investigations to determine compliance with any provision of this article. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.516 Well Inspection Reports. Any inspector who has inspected any work pursuant to conditions of a permit required hereunder and which involves drilling, digging, excavating or boring a well shall, not later than thirty (30) days after completion of such work, submit to the Department an accurate and complete well inspection report on forms satisfactory to Revised 4/15/16 7 ---PAGE BREAK--- the Public Works Director. Well inspection reports shall include all of the following: Permit number; Type and volume of sealing material and depth of seal(s); Diameter of borehole and well casing in sealing zone(s); Method of placement (if grout pipe, include number and length of sections); Confirmation that casing was ripped or perforated (destruction only); Conditions which may have caused sealing to be less than satisfactory; Date sealed; An opinion as to whether the well sealing operation was satisfactory or unsatisfactory certified by signature of the registered inspector; and Any other data required by the Public Works Director in the permit conditions. (Added by Ord. 2703-C.S., § 1, amended by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) 5-1.517 Abandoned Well Destruction. No person shall own or possess an abandoned drainage well deeper than ten (10) feet, an abandoned cathodic protection well deeper than ten (10) feet, an abandoned monitoring well, an abandoned engineering test hole deeper than ten (10) feet, or any abandoned water well unless such well has been either destroyed pursuant to this article or exempted hereunder. (Added by Ord. 2703-C.S., § 1, effective 3-15-90) 5-1.518 Certificate of Exemption. Any owner or lawful possessor of a water well or monitoring well which is abandoned or soon to be abandoned but who intends to use such well again may apply to the Public Works Director, in a form satisfactory to the Public Works Director, for exemption from the requirement that such well be destroyed. If the Public Works Director determines from review of said application that exemption from destruction would not pollute or contaminate groundwater and would not create or aggravate a hazard to health or safety, the Public Works Director shall issue a certificate of exemption. A certificate of exemption shall expire three years after issuance and may be terminated by the Public Works Director at any time prior to expiration upon the Public Works Director’s determination that destruction of the well is necessary to prevent pollution or contamination of groundwater or to avoid health or safety hazards. Successive certificates of exemption may be issued with respect to a well in the same manner as the original certificate. (Added by Ord. 2703-C.S., § 1, amended during 11-98 supplement and by Ord. 3129-C.S., § 1, and Ord. 3365-C.S., § 1, effective 12-9-04) Revised 4/15/16 8