HomeMy WebLinkAboutFDH Water Well PermitsMission:
To protect, promote Blmprove the health
of all people in Florida through integrated
state, county & community efforts.
rra
FILTH
Vision: To be the Healthiest State In the Nation
Ron DeSantis
Governor
Scott A. Rivkees, MD
State Surgeon General
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
Effective July 24, 2017
Contact the Florida Department of Health in Saint Lucie County (FDOH — St. Lucie)
prior to constructing or abandoning any well.
a. Call the FDOH — St. Lucie Well Line at 772-873-4936 or email
SLCDOH-WELLSCar7,FLHEALTH.GOV
b. Provide the following information:
i. Permit number
ii. Driller name
iii. Address
iv. Date and time to begin construction/abandonment
A minimum of 24 hours' notice is required before constructing any public water supply
wells. Please call our main office at 772-873-4931 and speak with Environmental
Health Staff or provide notification by email to SLCDOH-WELLSPFLH EALTH. GOV
• Submit revisions to permit and/or site map and associated fee within 48 hours of well
construction or abandonment.
Florida Department of Health
St. Lucie County
5150 NW Milner Drive • Port St Lucie, FL 34983
PHONE: 7721462-3800 • FAX: 77218715360
StLucleCountyHealth.com
FILE COON VE
INAccredited Health Department
Public Health Accreditation Board
dottoop signature verification: rhPwai-'i [-3
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
❑ Northwest ('Denotes Required Fields Where Applicable)
❑St. Johns River
ng
❑South Florida The farm andwater forwardingthepererapactoris responsible rarcomptothe
thisfarmaedelegatdinrrhepermirappliplicabcation to the
D Suwannee River appropriate defegarcdauthoyiywhere applicable.
❑DEP
Cl Delegated Authority (If Applicable)
No.
Unique ID
6MIrI11111T.]
Stipulations Required (See Attached)
62-524 Quad No. Delineation No.
CUPNIUP Application No.
,,Sergio Fernandez & Gabrielle Hackett 6041 SW W 8th Ct Plantation, FL 33317
'Owner, Legal Name if Corporation 'Address 'City 'Stale 'ZIP Telephone Number
2.18601 Tranquility Base Lane Fort Pierce, FL
'Well Location - Address, Road Name or Number, City
3.3215-801-0071-000-6 18 3
'Parcel ID No. (PIN) or Alternate Key (Circle One) 1 ^K Block Unit
4, 15 36S 38E St Lucie Aero Acres Check if 62-524:❑ Yes ❑ No
'Section or Land Grant 'Township 'Range 'County Subdivision
5. Scott's Drilling, Inc. 11213 772-489-6117 scottsdrilling@bellsouth.net
'Water Well Contractor 'License Number 'Telephone Number E-mail Address
6.5014 Palm Drive Fort Pierce FL 34982
'Water Well Contractors Address City State ZIP
7. 'Type of Work: ® Construction ❑ Repair ❑ Modification❑ Abandonment
8. 'Number of Proposed Wells ONE 'Reason for Repair. Modification, ar Abandonment
9. 'Specify Intended Use(s) of Wallis): oe S PIR1.a
® Domastic ❑ Landscape Irrigation El Agricultural Imgalion ❑ Site Investigations L
❑ Bottled Water Supply ❑ Recreation Area Irrigation ❑ Livestock ❑ Monitoring
❑ Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation ❑ Test
❑ Public Water Supply (Community or Non-Community/DEP) Commercial/Industrial ❑ Earth -Coupled Geothermal DEC 2 3 2019
❑ Class I injection Golf Course Irrigation e HVAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ Commercial/Industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage
Remediet E] Recovery❑ Air Sparge ❑ Other (Describe) DO S U PtCOUr
❑ Other (Describe)
10.'Distance from Septic System if 5 200 ft. 1- T 11. Facility Description Single Family Residence 12. Estimated Start Date
13.'Estimated Well Depth 120 ft. 'Estimated Casing Depth 100 rt. Primary Casing Diameter 2 in. Open Hole: From —To ft.
14. Estimated. Screen Interval: From 100 To 120 ft.
15.'Pdmar/ Casing Material: Black Steel Galvanized ®PVC Stainless Steel
Not Cased Other:
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
18.'Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted ® Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Descibe)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From 0 To 100 Seal Material ( Bentonite ® Neat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neal Cement Other )
From To Seal Material ( Bentonite Neat Cement Other )
20. Indicate total number of existing wells on site List number of existing unused wells on site
21.'Is this well or any existing well or water withdrawal on the owners contiguous properrttyy covered under a Consumptive/Water Use Permit (CUPIWUP)
or CUP/WUP Application? Yes ® No If yes, complete the following: C%/WUP No. District Well ID No.
22. Latitude Longitude
23. Data Obtained From: GPS Map Survey Datum: _NAD 27 NAD 83 WGS 84
berobycodip Nall will mmpiywlet Ne appb'mble mbsol Ti0o40,Flonda Atlmlo1mIwoeodo, n1nalawato Imray Hallam Noownerof Nopropedy, Nallhoinfloo0onprovldedlsaraura,aMVacl smawaroormy
nepannetarani11.6.1 ama pen,uL irneedeq hoe teen orwm Ee obalne0plorbcommenmmenlolw¢V respmSibJitiefuMerelapler A3. Flmitle SleNlaA to maNla'vl arpopeM ebe,tlm WsweV; m, l0a4rylhmlem
censtruellon.IfuMurmNry mat all lnrmma0en prowl In Nis applil IS accurate and Nall will obtain No a0enl for Ne owner. Nal lha ln(omaVm pmWtledbemwete,aM Vail have Nfamred Ne wmerpr Heir
nemasary approval homoNarlodo,al, sUlo, orlOWlgOVarrvnanb.IteppllWdB. 3agnatoprovlCeawall remanslbllilleee¢stetedal ewnermnsenN to allw.lnp p¢rBOM¢I of NIS WMemDobgaled AUNarM/aCCe59
mmple4an repo�roNa elsNawiflw,]edaya aeermmpbdon el Ne mnsWepon, repair, madiAmdan,ar bNe we1141e duNq Ne mnaW¢lion.repa'V,mNirW4on. or abandonmantauNalzW Ey N6 pemtiL
• -�,�d p� 1'r erV4tl4
X;QWmVYfitezdil Wr 13
•cenIgna ure or on[ractor se
No. 'Signature of Owner or Agent 'Date
Approval Granted By — Issue Daley Expiration DaleK 3/ & Hydrologist Approval
Fee Received S Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES.
DEP Far•• 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October 7, 2010 Pagel of 2
dotloop signature verification: ddp gC+13
Permit No.
SOUTHWEST FLORIDA WATER MANAGEMENT DISTRICT
2379 BROAD STREET, BROOKSVILLE, FL 34604-6899
PHONE: (352) 796-7211 or (800) 423-1476
W W W.S WFW MD.STATE.FL.US
ST. JOHNS RIVER WATER MANAGEMENT DISTRICT
4049 REID STREET, PALATKA, FL 32178-1429
PHONE: (386) 329-4500
WWW.SJRWMD.COM
NORTHWEST FLORIDA WATER MANAGEMENT DISTRICT
152 WATER MANAGEMENT DR., HAVANA, FL 32333-4712
(U.S. Highway 90, 10 miles west of Tallahassee)
PHONE: (850) 539-5999
W W W.N W FWMD.STATE.FL.US
SOUTH FLORIDA WATER MANAGEMENT DISTRICT
P.O. BOX 24680
3301 GUN CLUB ROAD
WEST PALM BEACH, FL 334164680
PHONE: (661) 686-8800
WWW.SFWMD.GOV
SUWANNEE RIVER WATER MANAGEMENT DISTRICT
9225 CR 49
LIVE OAK, FL 32060
PHONE: (386) 362-1001 or (800) 226-1066 (Florida only)
W W W.MYSU WANNEERIVER.COM
Comments: i
Sf•!e Piw� ✓�+- 'A"a,
e,or%,t+% ul-60 4ij 'xy5 cQ 46
*General Site Map of Proposed Well Location
Identify known roads and landmarks. Give distances from all reference points or structures, septic systems, sanitary hazards, and contamination sources, if applicable.
DEP Form 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October7, 2010 Page 2 of 2
CABAGEPALM
CABAGEP
*23.3
CABAGE PALM
x t 22.4
x 22,7
,n
COVERED
0 ENTRY
67.9• 22.69
J 29.0'
229
n 23,3
CABAGE PALM 22,68
x t 22.5
ow-3-Tom
23.1
o O Q 23,10 x
N
21.34�
N �
15.8'
u 23,0 x
A
LOT 18
OCCUPIED
22,68 "
77• 2s.o• 2W
w
.
y P
PROPOSED / y'''• C
1 STORY 9BS ;
RESIDEPaCE
FFEA 26.0' w '
PORCH P
28.7'
PROPOSED 23.1
POOL
AREA w
45.0•
0�=w
0 LU Q 530' 22,9
EXI TING WELL
'C4's 170.13'
x 23,8
E 260.00" N 890579
23.28
MA
22.7
ROPOSEE
ONCRETI
\ 23
OSED
LINE \
�0 22.8
75.0'
PROPOSED
WELL
CONCRETE
PROP
WATER
1 2
o /
EXISTING
2,9 HA- GER
n �FFE=25.0'
V
N
ry C
60.00• 3(
NF :� � . ..'.. � ..• a .� :�P
CONCRETE•:
0 8.9s'
'.50.00•....