HomeMy WebLinkAboutWater Well Permit ApplicationSTATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON AWELL
❑Southwest PLEASE FILL OUTALL APPLICABLE FIELDS
❑ Northwest ('Denotes Required Fields Where Applicable)
❑St. Johns River The water vied contractor is responsible for completing
❑ South Florida rMs twit and fa warding the permll application to the
OSuwannee River apWopdafedelegated authority where, applicable.
❑ DEP
O Delegated Authority (If Applicable)
Unique ID
Stipulations Required (See Attached)
Quad No. Delineation No.
'Slate. 'ZIP 'Telephone Number
3.
tercel 0 �Np (PIN) orAl(e (e (Circle O,ey nL Block Unit
4. _ w Z 3 � E
'Sec' n or La d rant hip'rRange C my Subdivision . , Check if 62-f _Yes _ (/ No
s. fzC?i ds3 3�/9/�f997 dhi//��9 Se�vis@aD/Goy,
' ater vyell Co clor license Number lephone Uoiber E-mail Address�i
6._ /v2,r¢� _Q�'t�l'!`4,10V 5`T-A�Ui ll//YI ¢lam a?67
7.'Type of Work: Y Construction —Repair —Modification —Abandonment _
8. 'Number or Proposed Wells _/ t
�9. `S city Intended Use(s) of Well(s):
mestic Landscape Irrigation —Agricultural Irrigation
—Bottled Water Supply _Recreation Area Irrigation —Livestock
_Public Water Supply (Limited Use/DOH) Nursery Irrigation
Public Water Supply (Community or Non-Community/DEP) —Commercial/Industrial
—Golf Course Irrigation
—Class I Injection
site Investigation
_Monitoring (� w \tiY/J J
—Test
—Earth-Coupled Geothermal ryt�p
-HVAC SupplyJUL 1 !-7 281y
HVAC Return
Class V Injection: —Recharge —Commercial/Industrial Disposal _Aquifer Storage and Recovery_Drainage
Remedialion: —Recovery —Air Sparge—Other (orsrn2al_ —.— r I se
_Other(oadaibd),'D (Note:Net .0" pl �I apermlluidbyagivanperMax,;raw NVIRONM
10.101stance from Septic System if s200 ft. 11. Facil! ption 12. Estimated Start Dale
13.'Estimated Well Depth ft. 'Estimated Casing Depth. 'Primary Casing Diameter in. Open Hole: From_To_fl.
14. Estimated Screen Interval: Frorryw,&Lfl.
15.'Primary Casing Material: _Black Steel V Galvanized _PVC _Stainless Steel
. _Not Cased Other. - ._ _. ..... .......__-....---
._ .. -_. _ ._
16. Secondary Casing: _Telescope Casing _✓" Liner _ Surface Casing Diameter in.
17. Secondary Casing Material: _Black Steel _Galvanized 7 PVC _Stainless Steel _Other
18.`viethod 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 (Dasvlbal
19..Propose Grouti7B� at for the Primary, S;adndery, and Additional Casing:
From!:E7 al Material (_ V Benlonfe Neat Cement - Other )
From To Seal Material ( Bentonile_Neat Cement Other )
From To Seal Material _Bentonite Neat Cement —Other— 1
From To Seal Material (_Bentonite_Neal Cement , Other 1
20. Indicate total number of existing wells on site -.9?— Lis( number ofexisting unused wells on site
21.'Is this well or any existing well or walerwith wal on the owner's contiguous property covered under a Consumptive/Water Use Permit(CUPWUP)
cr CUP/WUP Application? _Yes No If yes, complete the following: CUP/WUP No. District Well ID No.
22. Latitude /,r�'ongitude
23. Data Obtained From: _GPS V Map _Survey Datum: _NAD 27 _NAD 83 _WGS 84
I r!ereY• emery 0s+11 Mi rwaFj 1b WapplienUe M= er Me+e. F11d.MC 1ea6,o Cod; IWeula Jet Ireed"U I. pn a+ &Na mgsMY•Died dm inlp.rotim pp.idb113emuaL•, endpul I.. a de,
Vie pennll C. odiWy,e linqupaml,OnaedvQ lu.bsenvx9 La wein-d ryie,W ne'en.mon!a 1K .ewone31fJM1S under Ginp!el373. FIrnda Sirdece/b mSneW w WoFerly apuWai Nw•a: y I ecedy W! I W!
wnirrveian.IfwN<rewOyNdt plllnipmld!iw pmldedm Ws wpiwlbnb..e. and da: 1 rn.bab Nea0anl rw Nedemcr. Innl No inrmmodpn pevltlptl is arru.ale. and Owl l law Flwmetl Pe rimer orWi'r
neuavryapVmNeml odor limal,stile,aaerogovem_Trnh.[aopfoGa lxittgpd ideo»2r «=w,dbISOSeees!o¢dabwe. (+✓loran" to WI inDUeSxxeJaldis MID ar DekjL-d+L:eoay eeci
pamNedw rtpmyyyy Ne DbWavr.Lrvl 30daya anw exn Mm er Neeurilne wtepS.apNeWdw.d1 IS Om w19 sllc dumry de, eonsWcdon.mpeir. inadaipdw. mnbanderanen, aWmnsed by Nis pemd
daiwmc.'CRudied pYeda pemdt WL'annll peNaammapaL ,,
e D53 e� o t l toy
' ignafore of Contractor iF 'License No. 'Signature of Owner or Agent 'Date /
Approval Granted By
Fee Received S_
THIS PERMIT IS NO
Issue
Expiration Date
Receipt No. Check No.
THE
DEP Form:62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Dale: October 7, 2010 Page 1 of 2
ASEM NT
I�t
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i
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50- 198.�O-\
0
X9�O
I I i PROPOSED
WELL
ti
I O.B. \
/
o — ' ' 52.56 7.28
97.50
PROPOSED
3STORY CBS y N a
ANd
D TANK RESIDENCE 1 R •7:28' F.F.E=TO BE
O DETERMINED
PROPOSED p P.ROPOSED0
' \ I 1200 GAL. =m :;;'.CONC ;DRIVE `C' �+ 00'
SEPTIC TANK
=,1 PROPOSED 1'
375 GAL.
p
\ PUMP TANK 0• CONSERVATION EASEMENT—
'�!CL SWALE 1' ` / TREASURE COAST AIRPARK
1 P.B. 26, PG. 18
II `� ��; I `97.20
—30�-y 30' TAXIWAY EASE ENT .96.20
60' TAXIWAY EAS ME \
O�
=;` 1 PROPOSED CON DRIVE r W
0 01
I I PROPOSE -
'4 i
II
r97.50
D
—48 QUICK 4
EQUALIZER 36
CHAMBERS
(4 ROWS, 12 CHAMBERS
PER ROW)
576 SQ. FT.
`•Dt U NOBSOTRUCTED4AREA
! =s LOT 65
O
co
;n I
to
z1/—VEGETATION LINE
STATE OFFLORIDA PERMITAPPLICATION TO CONSTRUCT,
REPAIR,:MODIFY.ORABANDOMA'WELL Pene1A'o. �r7.� J.11'�tOdO
1 OSoathwest PLEASE FR10UrAL1AFit1r/aLF1E1.06 Huri� Unrquo ID
ONorthwest (•Dergtes RequIred:F[aide Wnere App➢cabta) Porldt Sdputaeons Raquhd(S"AttacI;9Q
OSL Johns River 7ae lvaavrmconattbrhros➢eu8+b krrargbtiry
OSOulh Florida LYsraaand(arvrmBry 65a➢o:1aSCAi'W/mm?a 52.524 Oaad No._OeHnaefion No
OSuwannee River .Avopfafc da"9 daltneiyldmm w6h
'ODF� �1CLIPNVUPApplicanen Na
._.✓�� 8'6elegated Authority (tfApp,4pbie) ��/T .._.,:
,. 6�ac,e 1 pe'r .S ? a a7 V, G G 903oy-�si-ziay
•Owner. Legalfftma' •City, •State ZIP •Telephone Number
2. ! 3 G
'Well Lo lb , AW1 Rc Number Cky
02
•Parcel ID No. (PIN) orAttemaalP Key (Cbcre a Lot Block Unit
a. 975 3,� �GGC tI v I/
•S or n Grant :--�To p_ •R' ge County- Subdk,Lslon ,/ Chock if 62.524: Yes _ No
5. I d• ice _ %06� ��'/9/�999�f clrl//inrySev
gvrcrs�RO/•Corn
•WeterWel clot Yfeanse Number 'Tq onsN r E-ma➢Address
6. 1,V4 eke ghItIm ST.Oc4J . 'Aaymf " • nC7d .3990.
7. •'iype of Work:=ConsWction7— Repair _Modificabon Abandonment •Itr�n�RraiO N.anuuon, orAavefarcmnt
8,'Number of Proposed Welt �/_
9,'Specify intended Use(s)of Wei
_Domesll Vescapa lrrigallon Aricuurai�lrtlgadan _P L`
_Botilad Water Supply _Recreation Area Irrigation _Liveslocc _Monitoring
_Pub➢c Water Supply (Limited UmMOH)—Nurseryh tgatem _Test
_Pm Ub➢o Water Supply (Community or Non-CommurdtylDEP)—ComnreraalMdustrial1f Couse lrtigadon " _Earth -Coupled Gaatherm Y 2 4 2018
----.glass ) Infection _HVAC Supply HVAC.Rebrn
Class Injection: _Recha:ge_Commercalllndustrial Disposal Aqu➢er Storage and Recovery_Dminage
Remadlation: _Recovery AIr Sparge
'Distance from Septic by Qt 17 s200fLU•=n s)'t`" 12. Estimated Start Date /TavnY
•Estimated Wall Depth �N!/—RE2s/t/ImaI Casing Depth (r%� •Primary Casing Diameter_In. Open Hot.: From To_R
Estimated Screen Intervat F10 ✓ n/ 7 fl.
'Primary Casing Materiab _Black Steel Y G =Ized _PVC _Stainless Steel
_Not Cased Other.
Secondary Casing: _TeEscope Casing _Liner _Suif7g Wameter in.
Secondary Casing Material: _Stack Steel _Galvanized —7p�/C _Stainless Steel _Other
'Method of Construction. Repair, orAbandomnem: _Auger V Cable Tod _Jetted _Rotary _Sonic
_Cotnbinmien (Two or More Methods) _Hand Driven (We➢'Polm, Sand PolnQ Hydrau➢o Point (Direct Push)
_Horizontal DriOing _Plugged byAppmved Method _Other (ocaom.l
Propos�rwfingiYWe _ far the Primary, SV4dmy and Additional Casing:
20. Indicate total numberof existing wells on site Ustnumbarolerdstf unusedwellsonstta
21.•la this we➢orany ed%Ungwo➢orwaterwithQrawalon the omees contiguous propertycovered undera ConsumptivelWaterUse Perm➢(CUPIWUP)
or CUPIWUPAppIsation7 Yes _No It yes, complete ure WaA*u: CUPIWUP ND. District We➢10 No.
22. Latitude ii'ong➢ude
23. Data Obtained Fmm:_GPS )_/ Map _Survey Dabm:_NAD27 _NAD 83 _WCS84
IaNp'dW a+tlNm1,71mb hSmd+ernma4ranrsa,ua.u4ra.1).ay. Im'+rnYl.nw mlrr.rw�.Y. wl W w.um.c�.'�a.®w rbinw....av
W)r��rYYNl11)oaf1.MK)Clel,(IYrMf�YY(tllbCr�6mwv�p)yN On,Y Yfm1.SY104IM1arAl AlllaWW\blMl/�1YMrYM)All Nf �)D411®1 W11N
mtXNi lEf4lef lllM.lvN011 ).s.'talebq�ebbpv¢hr MlMab)b H4NbMmt1YW N01a�fi)PmMe6!)maYIWCCIMwvOWwiv,rOW
be)yapalaermm�Wd.d4a fr)paad,. Irew baA•.I.M wapvtnMaemM)MM.Om11mMMab.bJbpbabNlaUYNYC weeper a.eoy.un
s�n.Tl MY,�.MK.aOuy. _ °�±I.O•.,.)a.�IMY b.wwaW/,vif Wlol,IMM1n1✓.NMuba V•llWmtim9[dml Y/Caq.�
Approval Granted By
ly
Foe Rerebed$ Reedit NM
'E.paollon Date r/ q t I Hriudog6tAPProval w�
kwoq;=led b 62;572.400(Q, FAC. ESedivo Date: Odd+a T. 20d Page 1 or2
""""" ND. 1/2" I.R.C.
"RLS 2391"
u BM-98.99 (TOP OF I.R.C.) RUNWAY LIGHT
98 39 RUNWAY UG
98.08-\,4/ T.O.B._ — . — — • _
98.99 �•gm
N88'41 50 E 400.04
96.s
96.77 INV 96.09 30' DRAINAGE EASEMENT
INV � _ CL SWALE .._ --96 —
97.30 I o yhcb
I —
xCb a 9� 1 97.74 T.O.BT 98.06
i l xc9b. o WOODED 7. \� p
w \rh•9
1 I II
II PROPOSED t
WELL F I
XO
III .O.B. N
103.39' � 17.44
52.— \7.28'
a F /
9.60�II f56
�i8�.70� �69 r' 97.50 s. PROPOSED ri o
\x�l 9� 90� j 3 STORY CBS i N a/
WELL PUMP RESIDENCE 9-28' /
17.70 I I I I LI AND TANK o F.F.E.=TO BE j W.
DETERMINED
t
R -PROPOSED-' . ' �3p0 /
PROPOSED .b CONC'• DRIVE . " t 0 I 1200 GAL.�••..., -,•:.... ,.; ..
I{ I I SEPTIC TANK
�I PROPOSED
375 GAL
f I I\\ PUMP TANK /
!Cl_ SWALE
EASEM NT 0' 0') 30' TAXIWAY EASE NT OI
60' TAXIWAY EAS MENT M)
I � �
M
I( } II W)
.PROPOSEO CON 'DRIVE p)
,.,i.; ..,.•.. ......, , e d••
w I PROPOSED '• �)
96.I0 NI II 48 QUICK 4
_ EQUALIZER 36 ZI VEGETATI(
F 4. I I CHAMBERS
U I 0 I II (4 ROWS, ROW) 1PER CHAMBERS )
3 I I i 576 SQ. FT. 30,0 )
o < CV I I I I'• ? PROPOSED 864 S.F. )
UNOBSTRUCTED AREA
a LOT 65
zL
98.20 cn p� � 98.05
8.50 < �, 97.50 �.
•� x9 I x�
37.50