HomeMy WebLinkAboutWater Well PermitsMission:
To protect promote & Improve the health
of all people In Florida through integrated
state, county & community efforts.
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R MY
HEALTH
Vision: To be the Healthiest State in the
Ron DeSontis
Governor
Scott IL Rivkees, MD
State Surgeon General
2:8 1020
ST. Lucie County, Permitting
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
SLC DO H-W ELLS(a) FLH EALTH.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-WELLSaFLHEALTH.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: T72/462-38DO - FAX T721871-5360
StLueleCountyHealth.com
Accredited Health Department
Public Health Accreditation Board
I
STATE OF FLORIDA PERMIT APPLICATION TC CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
�U di �11 SGUUIWGSI PLEASE FILLOUTALLAHRUICABLE FIELDS
*'Northwest (Cles Required Fields Where Applicable)
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Clued No. ypaaneaEan No:_
507 Thames Bluff Ridge For Pierce FI 34962 443-277-3254
,. Kathy Orlousky
'Owner. Legal Name it Corporation 'Address dy - 'Slate -ZIP '7plephaono Number
2, 6702 Donlon Rd Fort Pierce FI �� 51
' Well Location.- Address; Road Name or Number, City `
61203900006 6 134 A 4
XParceilf) (PIN)orAllofnam Key(circle Una) Lot Block Unit.
A. 01 �yS 39E- St Lucia . Lakewood Park,
a
Chaeklr6e-524:—Yea _
'Section or Land Gmnt 'Township 'Range 'County Subdivision
11213 772 Fg-6117 scottdrilling(ftellsouth.net
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'Water'Water Weg tmctorlmctor 'License Numbor 'Telepho a Number --mailAddrsse
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ZIP
'Water Well ConbaLMr's Address 'CIS BIAIe LP
7. -Type of Work Construcilon _Repair _Modification Abandonment
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8.'Number of Proposed Wells 7q��
` Q
9. , !ended Uso(s) of Wall($):- V
Oemesli Landscapo Irrigation Agrieulltual Irrigation site Investigation'
ed Water Supply. Area Irrigation _Livestock Monitoring
_ _Recreation
_Test
Public Water Suppl .Lirlylea Uea/DOH) _Nurserylydgation
Y( Crumnerclalllndustrlal _Earlh-Couplad Geothemml
FMA 1 220
_Public WaLer$upply(Community or Non-CommunitVIDEP)_Golf Course lnlgalion _HVAC SUCPiy
_Class I Injection _HVAC Return
Gass V Injection: _Rechargo JCommerciaHituldSlral Disposal Aquifer Storage and Recovery _Drainage '
Remediallon: _Air Sorge _Other laYwmq_ _F!l ljtdeudq
_Recovery
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10.' stance from Septic System if4200 h. - IT. Fadlay On sedptien �i"Rt /a BiYIL� _ . 12. Estimated Start Doto
Estimated Well Depth �It. -Estimated Casing Deolh�fL 'Primary Ca14119 Diameter y in. Open Halo: From_Tb_f
14. Estimated Screen Ir lelval: From l' OD TotZ'D ft.
15.^Primary Casing Material: !Black Steel _Galvanized _PVC _Stainless Steel
_Not Casad ,_-Other.
1S.Secondary Casing: Telescope Casing Liner _SurfacoCastua Diameter in.
17. Secondary Casing Material: _Black Steel _Gavanized _PVC _—Stainless Steel _Other
1S.'Molhod of Constnledon. Repair, or Abandonment' Auger �Cpble Tool _.lone Rot y Sonic
Comenatlon (Two Dr More Mathmin) Hantl Ariven{Wali Potnl. Sand.PoinU �Ny rau le ha (Diroot Puah).
_orizontal Drifliog __Pluggedby Appmvud Methad _... Othertoararacl
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19. Proposed Grouting interval for the Primary. Secondary, and
From 0 To,j, Seal Materiel (_Senlonim eat Centers Other )
From _7a_-Seal Material (_Benlonile_ meal Other )'
)
From__To-_Seal, Material l—_eentnllite_Neat Cement Other
Frcm_To_Seal Material (_pantonite_-Neal Cemenl•,__Oihar 1
20. Indicate total number of existing wells on site List number or existing unused wells on site
2i.'Is this well or any existing.wall or water withdrawal on the owner's contiguous property covered under ConslnnptivepNaler Use Permit ICUPM)UP)
_ or CUPIWUP Application? Yes No , es, compioto the rellowing: CVP WUP No._ District Wee ID No.
22:.LaUtude Longitude
23. Data obtained Flour: GPS _Map _Survey Datum:_NAD27 _NADB3 WG584
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rol Ca'e•1➢odar-- — - -- --_ 'LlCanao No. 'SrgnaturreaamwI d'Agent Date
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❑eo Rocaiwd'S Recolpt No. -__. OIIeCk Ne.-
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED MY AN AUTh.ORIZED OFFICER OR REPRESENTATIVE OF THE WMO OR DELEGATEDAUTHORITY. THE
ALL CONSTRUCTION. REPAIR. MODIFICATION, OR ABANDONMENT ACTIVITIES.
PERMIT SHALL BE AVAIbADLE AT THE WELL SITE DURING
Pnee 1 Z
DEP Form:82572.9e1)(1) Incomoroloe in aZ-SJZAuel]L nll.o...--•-
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