HomeMy WebLinkAboutSewageSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: D9Verton and Veronica Daniels
PROPERTY ADDRESS: TBD Johnston Rd Fort Pierce, FL 34951
PERMIT #:56-SF-1972780
APPLICATION #:AP1422523
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1246717
LOT: 4 BLOCK: SUBDIVISION:
PROPERTY ID #: 1327-806-0004-000-9 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND
T [
1,200 ]
GALLONS / GPD Septic New
CAPACITY
A [
]
GALLONS / GPD N/A
CAPACITY
N [
]
GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM PAPACITY SINGLE TANK:1250 GALLONS]
K [
]
GALLONS DOSING TANK CAPACITY [
]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [
575 ]
SQUARE FEET Drainfleld New
SYSTEM
R [
]
SQUARE FEET N/A
SYSTEM
A TYPE SYSTEM: I ] STANDARD [ ] FILLED
[x] MOUND [ ]
I CONFIGURATION: 1XI TRENCH
N
[ ] BED [ ]
F LOCATION OF BENCHMARK: Site BM #3 Set
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D I
0
T
H
E
R
NID'Rollins PLS 4945" circled In
[ 46.00 ] [ INCHES FT ] [ ABOVE kB—EL—OWJ BENCHMARK/REFERENCE POINT
[ 39.001 INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
REQUIRED: [Zb.UU] INCHES EXCAVATION REQUIRED: t 4L.VVJ lavc�s
system is sized for 4 bedrooms with a maximum occupancy of 8 persons (2 per bedroom), for a total estimated flow of
9pd•
SPECIFICATIONS BY: `ll Hunter A Collier
TITLE: Environmental Specialist I
APPROVED BY:
TITLE: Environmental Specialist I
St. Lucie CHD
Hunter A Co er
DATE ISSUED:
08/01/2019
EXPIRATION DATE:
10/30/2019
DH 4016, 08/09
(Obsoletes all previous
editions which may not be used)
Incorporated:
64E-6.003, FAC
Page 1 of 3
v 1.1.4
AP1422523 S 1
FILE S 1P
o„ STATE OF FLORIDA
DEPARTMENT OF HEALTH
p ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
wG:LL- Ko.
PERMIT NO. 54
DATE PAID:
FEE PAID:ri�5 Gk-Z32
RECEIPT #:
P>m- 4a
APPLICATION FOR: '
[✓] New System [ ] Existing System [ ] Holding Tank
[ ] Repair [ ] Abandonment [ ] Temporary
APPLICANT: DUVERTON AND VERONICA DANIELS
AGENT: JIM MA=
MAILING ADDRESS: 2267 NW PADOVA STREET, PORT ST. LUCIE, FLORIDA, 34986
[ ] Innovative
TELEPHONE: 772-216-9587
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: 4 BLOCK:
SUBDIVISION: POSTOBELLO
PROPERTY ID #: 1327-806-0004-000-9
PLATTED: APR.2004
ZONING: N/A I/M OR EQUIVALENT: [ No ]
PROPERTY SIZE: 5.015 ACRES WATER SUPPLY: [/] PRIVATE PUBLIC IV 3<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: JOHNSTON ROAD, FORT PIERCE, FLORIDA
DIRECTIONS TO PROPERTY: FROM THE INTERSECTION OF ORANGE AVENEUE AND ANGLE ROAD GO NORTH,
NORTHWEST AND WEST ON ANGLE ROAD TO JOHNSTON ROAD. GO NORTH ON JOHNSTON ROAD FOR
Aunrrr 2 MITES ON RIGHT ACROSS FROM MONTE CARLO COUNTRY CLUB.
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
SINGLE FAMILY
[ ] Floor/Equipment Drains
SIGNATURE:
[ ✓ ] RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1 Chapter 64E-6 FAC
4 3352
[ ] Other (Specify)
DATE: 07/02/2019
DH 4015, 08/09 (Obsoletes previous editions which may not be used) Page 1 of 4
Incorporated 64E-6.001, FAC
STATE OF FLORIDA APPLICATION # AP1422523
DEPARTMENT OF HEALTH PERMIT # 56-SF-1972780
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATION DOCUMENT # SE1194163
APPLICANT: Duverton and Veronica Daniels
CONTRACTOR / AGENT: Jim Maut2
LOT: 4 BLOCK:
SUBDIVISION: ID#:1327-806-0004-000-9
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 5.01 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 460 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 7515.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 1150.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1150.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Site BM #3 set mag NID 'Rollins PLS 4945" circled in orange paint
ELEVATION OF PROPOSED SYSTEM SITE 46.00 [ INCHES / FT ] [ ABOVE / ILELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM*THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: 15 FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 100+ FT NON -POTABLE: FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 100+ FT
SITE SUBJECT TO FREQUENT FLOODING? [ ]YES IX ]NO 10 YEAR FLOODING? [ ]YES [X]NOI
10 YEAR FLOOD ELEVATION FOR SITE: FT[ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES:
Munsell #/Color
Texture
Depth
I OYR 6/1
Loamy Sand
0 To 21
7.5YR 5/6
CMN/DST RF-
10 To 17
10YR 5/8
CMN/PRM RF
17 To 28
1 OYR 5/1
Sandy Loam
21 To 33
10YR 5/2
Loamy Sand
33 To 39
1 OYR 713
Sand
39 To 52
1 OYR 6/3
Sand
52 To 72
USDA SOIL SERIES:
Munsell #/Color
Texture
Depth
10YR 511
Loamy Sand
0 To 24
7.5YR 5/6
CMN/DST RF
14 To 21
1OYR 5/8
CMN/PRM RF
21 To 32
10YR 511
Sandy Loam
24 To 34
N 4/
Sandy Loam
34 To 42
1 OYR 6/3
Sand
42 To 72
OBSERVED WATER TABLE: 58.00\ INCHES [
ABOVE / BEE] EXISTING GRADE TYPE: [ PERCHED / APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:
17 INCHES
I ABOVE /
BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ]YES
[X]NO MOTTLING:
[X]YES I
]NO DEPTH: 17.00 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Sand/0.80
DEPTH
OF EXCAVATION: 42 INCHES
DRAIN£IELD CONFIGURATION: IX] TRENCH
[ ] BED [ ] OTHER
(SPECIFY)
- REMARKS/ADDITIONAL CRITERIA
r determined using USDA WSS and soil borings. 10YR 5/8 CMN Prom RF mottling In 10YR 5/11 matrix > 2% starting at 17" in
SB1 46" below BM. SB2 42.5" below BM.
SITE EVALUATED BY:
Collier, Hunter (Title: Environmental Specialist 1) (Florida Department of Health in St. L
DR 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
DATE: 07/17/2019
Page 3 of 4
\ AP1422523 EID1972780 V 1.0.2
NOTICE OF RIGHTS
i
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one (21) days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order will
constitute a waiver of your right to an administrative hearing, and this order shall become a 'final
order.
Should this order become a final order, a party who is adversely affected by it is entitled
to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are
governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced
by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a
second copy, accompanied by the filing fees required by law, with the Court of Appeal in the
appropriate District Court. The notice must be filed within 30 days of rendition of the final order.
1d
HEALTH
PAYING ON:
RECEIVED FROM
PAYMENTFORM:
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
#: 56-SF-1972780 eILL ooc #:56-BID-4244719 CONSTRUCTION APPLICATION #: AP1422523
Jim Mautz AMOUNT PAID: $ 660.00
CHECK 232 PAYMENT DATE: 07/08/2019
MAIL TO: Duverton Daniels
FACILITY NAME:
PROPERTY LOCATION:
Johnston Rd
Fort Pierce, FL 34951
4
Lot: Block:
Property ID: 1327-806-0004-000-9
EXPLANATION or DESCRIPTION:
QUANTITY
FEE
128 - OSTDS Construction System Inspection Research Fee
1
$
5.00
-1 - Surcharge (All)
1
$
45.00
-1 - OSTDS New Permit Surcharge
1
$
100.00
-1 - OSTDS Construction Application and Plan Review,New
1
$
100.00
123 - OSTDS Construction Site Evaluation
1
$
115.00
126 - OSTDS Construction Permit (New or Mod, Amendment)
1
$
55.00
127 - OSTDS Construction System Inspection
1
$
75.00
133 - OSTDS Construction Reinspection
1
$
50.00
-1 - Well Construction
1
$
115.00
RECEIVED BY: EvansJS AUDIT CONTROL NO. 56-PID-4009250
0(1lE $r -
q„ STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREA
a� �� .
SITE EVALUATION AND
TME
NT AND DISPOSAL SYSTEM
SYSTEM SPECIFICATIONS
PERMIT #.
APPLICANT: DUVERTON AND VERONICA DANIELS AGENT: JIM MAUTZ
LOT:4 BLOCK: SUBDIVISION:POSTOBELLO
PROPERTY ID # : 1327-806-0004-000-9 [ Section[Fownship/Parcel No, or Tax ID Number ]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [✓] YES [ ] NO NET USABLE AREA AVAILABLE: 5.015 ACRES
TOTAL ESTIMATED SEWAGE FLOW: GALLONS PER DAY [RESIDENCES-TABLEI/OTHER-TABLE2 ]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/REFERENCE POINT LOCATION: (SITE BENCHMARK THREE) SEE S
ELEVATION OF PROPOSED SYSTEM SITE IS 3.2 [Fr ] [BELOW
POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 75 FT DITCHES/SWALES: 15 FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC: 200 FT LIMITED USE:100 FT PRIVATE: 75 FT NON -POTABLE: 50 FT
BUILDING FOUNDATIONS:5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES:10 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
bUlL Y1(U!'ll 1MAVitCJtiXV" aiiM c
MUNSELL #/COLOR TEXTURE
USDA SOIL SERIES:
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
OBSERVED WATER TABLE: INCHES [ABOVE/BELOW i] EXISTING GRADE. TYPE: [PERCHED /APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
07/02/2019
INCHES
DH 4015, 12/11 (obsoietes previous editions which may not be used) Incorporated: 64E-6.001,FAC Page 3 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[.I] New System [ ] Existing System
[ ] Repair [ ] Abandonment
APPLICANT: DUVERTON AND VERONICA DANIELS
AGENT: JIM MAUTZ
MAILING ADDRESS: 2267 NW PADOVA STREET, PORT ST.
[ ] Holding Tank
[ ] Temporary
FLORIDA, 34986
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] Innovative
TELEPHONE: 772-216-9587
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: 4 BLOCK:
PROPERTY ID #: 1327-806-0004-000-9
: POSTOBELLO
PLATTED: APR.2004
ZONING: N/A I/M OR EQUIVALENT: [ No ]
PROPERTY SIZE: 5.015 ACRES WATER SUPPLY: [V] PRIVATE PUBLIC [l/]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ]
PROPERTY ADDRESS: JOHNSTON ROAD, FORT PIERCE, FLORIDA
DISTANCE TO SEWER: FT
DIRECTIONS TO PROPERTY: FROM THE INTERSECTION OF ORANGE AVENEUE AND ANGLE ROAD GO NORTH,
NORTHWEST AND WEST ON ANGLE ROAD TO JOHNSTON ROAD. GO NORTH ON JOHNSTON ROAD FOR
4BOUT 2 MILES ON RIGHT ACROSS FROM MONTE CARLO COUNTRY CLUB.
BUILDING
Unit Type of
No Establishment
1 SINGLE FAMILY
2
3
4
[ ] Floor/Equipment Drains
SIGNATURE:
[✓]
[ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1 Chapter 64E-6, FAC
4 3352
[ ] Other (Specify)
DATE: 07/02/2019
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4
Swe sG
8 STATE OF FLORIDA
' r DEPARTMENT OF HEALTH
ONSITE SEWAGE TREA
SITE EVALUATION AND
TME
NT AND DISPOSAL SYSTEM
SYSTEM SPECIFICATIONS
PERMIT #.
APPLICANT: DUVERTON AND VERONICA DANIELS AGENT: JIM MAUTZ
LOT:4 BLOCK: SUBDIVISION: POSTOBELLO
PROPERTY ID # : 1327-806-0004-000-9 [ Section/I'ownship/Parcel No. or Tar ID Number ]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN:
[✓] YES [ ]
NO NET USABLE AREA AVAILABLE: 5.015
ACRES
TOTAL ESTIMATED SEWAGE FLOW:
GALLONS
PER DAY [ RESIDENCES -TABLE T/OTHER-TABLE2
]
AUTHORIZED SEWAGE FLOW:
GALLONS
PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE
]
UNOBSTRUCTED AREA AVAILABLE:
SQFT
UNOBSTRUCTED AREA REQUIRED:
SQFT
BENCHMARK/REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE ]
PT ] [ BELOW ]
POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER:75 FT DITCHES/SWALES:15 FT NORMALLY WET? [ [ YES [ ] NO
WELLS: PUBLIC:200 FT LIMITED USE: 100 FT PRIVATE:75 FT NON-POTABLE:50 FT
BUILDING FOUNDATIONS:5 FT PROPERTY LINES:10 FT POTABLE WATER LINES:10 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFI" 1lVrr kWwx1uw a�ir. +
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
G
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
USDA SOIL SERIES:
TO
TO
TO
OBSERVED WATER TABLE: INCHES [ABOVE/BELOW 1] EXISTING GRADE. TYPE: [PERCHED /APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: '[ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
: 07/02/2019
INCHES
D8 4015, 12/11 (obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 3 of 4
STATE OF..FLORIDA PERMIT APPLICATION'TO CONSTRUCT,.
REPAIR, MODIFY, OR ABAN60N ANWELL
OSOuthwest PLEASE FILL OUTALLAPPtICABLE FIELDS _
s ❑Northwest ('DenotesRequired Fields Where Applicable)
OSt. Johns '.River Tire wdtery2!(wmracWtsresponsloletar rompleting
❑South Florida this rMMand knmr&ingMePerna appccanon te me
❑Suwannee River eppnpdty derma ..woay» teppft ma.
❑DEP
❑ Delegated Authority (If Applicable)
•Range - 'County
01
"Ucense Number "Teie
Unique
- sF - ta*1 a-t�5o
Required (See Attached)
Quad. No. - Defineatlon No.
�L � 3yv--Ias
Slate P 'Telephone Number
Block - Unit
Cheek if 62524: _ Yes _ No
gerof Pmposed Wells 1 ---- Kew.. "ma'"` ki°i°�7 D.
O -
gEE
;ifylntended,Use(s) of Well(s)i L,i�.11J—
-
_
mestic Landscape Irrigation _Agricultural Irrigation Site Investigation S
"2R1:4
(tied Water Supply _Recreation Area Irrigation' _Lh estock'. Monitoring
Irrigation Test AU.
ff `�
1 2019 Yh
iHo Water Supply,(Umited Use/DOH) —Nursery _
Commeridalllndustral -Coupled Geothermal
-
_Earth
Elie Water Supply (Community or Non-Communtty/DEP)—Golf Course Irrigation - HVAC Supply
+
ssI Injection
_HVAC.Return''
Injection: ._Recharge_CommerciaVlndustdal- Disposal -Aquifer Storage;and Recovery ---Pm DOHi �StLude Count/
ENVIRO MENTAL HEALTH
dion:, _Recovery. _Kr sparge =other (Dew e)
- - -
Official Use OM/
er(newite) - __ Now; NoteD types MwdL erepewlEedbyagban pemdUing autl rql
nce from Septic S m if 5200 fl. 7 S' 11. Facility Description 6!lk nZe. 12. Estimated Start Date Jv /I-
iated Well Depht ft 'Estimated Casing Depth 8Q fill. 'primary Casing,Diameter0—" in. Open Hole:
From. e Ta=R
Estimated Screen interval: Fromj—Z)—Trcn? R Z/
'Primary Casing. Material: Black Steel V Gavanized _PVC _Stainless Steel
Not Cased Other
Secondary Casing:. Telescope. Casing _Uner� Surface. Casing Diameter in.
Secondary Casing Material: _Black Steel. _Galvanized PVC _Stainless Steele. Other -
'Method of Construction, Repair, orAbandcament _Auger ZCable Tool _Jetted Rotary _Sonic
Combination (Two or More Methods) Hand' Driven (Well Point, Sand.. Point) _Hydraulic Point (Direct Push)
_Horizontal DiHfng _Plugged by Ap�pfoved Method. _Other (oPsarnel -
Indicaletotai numberotexistingwellson site _ - Listnumberofexisting unusedwells on site,.
'Is thiswell orany existing well orwaterwithwal on theowner's contiguous property covered undera ConsumptivaWater Use Perk (CUP/WUP)
or CUP)WUP ApplicatioM_Yes._No if yes, compietethe following: CUP/WUP No. District Well ID No. -
22. Latitude Longitudes- - - -
23.Data Obtained From:_GPS _Map _Survey Datum:. NAD27 _NAD63 WGS84
Approval Granted By
Dar —to
Hydrologist Approval
wnm
Receipt No. Check'No.
Fxpiration
In62-532.400(1),
THE
Page 1