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HomeMy WebLinkAboutWell Water Permitt # ot�fPLa a� STATE OF FLORIDA PERMITAPPLICATIONTO CONSTRUCT; s,_ t REPAIR MODIFY�;ORABANDO(�AWELL a PerniltNo 59'30379j ❑Sduthwest1 Florida Unique ID PLEASE FILL OWALLAPP ICA9LE FIELO6 1 _ e 1 k, a ONoiihwest' 3(Denotes Required Pettis Where App4cable)Pamiil SUpulaVons Regmred (Sae A(ieched), 9r fiewarrrwtlfmnfranorlsrc�p nrl6lcr «omplefinq xp iy� SOufh Fonda, Ws/orin nJf Mnprhepmnle pplrrefi mMe 62 a?40ead ND i '� DetlneaF on No t Oa lri'R fr appr prlawddgaredoufM1ulywh reoppRm6le ❑DEP ! + 3 CUPAMIP APPIIoadan ND 1 ❑ Delegated Authority (IfApplimum cetife)) ^ r 1 National Tax Asset , 2740 SW Martin Downy BIGd #240 +Palm Cltyl FL`348901 '; It Owner Legal NamelfCoryorallon Addressx +:'City) 'Stele 'ZIP, t TelephoneNumFier ' 2tl5120.5arillielAvenuezFort r Y Veil Location Address -Road Name er.NOmber C 3 a1301�15 0093 000 3k . 107 12 A' s ParcellD'No (PIN)or Alte 34S3y(Clr'3:Orb) " Lot Block Unit+ 4112 Lakewood Park' Check If 62 524.❑ Yes ❑ No k Section or Lend Grant] ;'Township' - ":Range' •. ` County •`. Sub an' Scotfrsbrillinq,Inc _: 11213' `,,;:772469-8117+ sbttsiirlllinoL�heilsoiitli"net 4 i } *Water.Well contractor{"=> Ucenae Number "'Telephone Number _ E-mail Address) s 5014 Palm Dnve> s Fort Pierces.: F.'L 34982 t _ ,I « 'Water Well Contradora Address ' City __ Stale s ZIP.x- _ a i r 7 'TypeotNlddc ©Cortstruotion ❑)Repair ❑,ModdcaUon� Abandonment,-'-> t .D UF D( 'B I Number o(Proposed Well's ONE' ' _ Reeeonlo(flepdr WWI R �a _ F 9.1 Speolfy, Intended Use(s) Of We'II(s) s e✓ IDamestlq; 8jlandscape lmgalion t e Agdculfuralhdgatlon. 8; Slte lnva"stigabons •.U���j_ 1 3BoWed Wetar Supply Recreetion/vea lmgauon ti)Uvestpckf Monitoring, r r Pubec Water Supply (Umi'ted UsefDOH)'a ' ' `Nufe6iy lnlgahon'f ,' 'Test ". �AR'�= Public Water Supply (Community or Non-CommunitylDEP)+ CommerdaVlndustdI.a( iEafth-Coupled Geotheimah' ' j Classl Injection - �x °GoHCourse lmgello'n ''HVAG Supply t Hvnc_Ixewm F H �(1'St LUC19 Co y) a CWss V Injection ❑ Recliajge) ❑ dommerclaHlmlusidal Disposal k® Aquifer SloFage entl Rewvery ❑ Drairi�N k&alENTAL`H _ f` ' t2emedlaUon'RecoveryO Alr Sparga ❑Other (0utlulna) 'a '� s _ - `��. ,Otndat Use On , - ) • .t r P � ; 10 (stance from SepUc System if 5200 R' 1 t 'Faallty Descnpv,n mg a am y esl once r 12 Estimated Start safe -- -_ r:. tl - - 'Esbmataid Nw1 Depth 120 ft` Estimated Casing Depth 1001 ft. Primary Casing Dlemeler .'2x In Open; Hole From -` 14 EsUmaled ScreenlnlerihilAom 100 'To 120 g,' 16-PdmaryyCasing Material:, Blade Steel , GalVanlz f4 ✓PVC Stainless Steel ' 1 ' • � Not Cased Otlie� �' -- -' � - 16}Secondary; Casing Telescope Cdsjng), Liner Suiface:Casing^ Diameter in, f .• - 17 SecondiFy Casing MatenaL•. Blade Steel Galvanized , PVC Stainless Steel Other 18'AAelhod of Conslrudfon'Repair or AbandpnmanL `,Auger .Gable Tool Jetted -A Rote Sonic ,.. Camhina6an (Twp orMom Methdtls) Hand Ddvan (1NeIl PolnL Sand Polnl) Hydmu Ic Point (Diced Push) !_. Holiontsl DriV(ng}, ••,Plugged by APProveAMelhad ^'4Olher (paedfoa) �- 19 Proposed Gnugng Interval for the Primary Seeondery,end Addi ,:. n ' r 1 From 0._ To idOL Seel Material( IBento` V, Neat Cement/ Oilier From To _ Seal Material (' Benlonl ' ,' Oilier 1 From _ jo - Seal Mateiiat( Benlonlfe Neat Cernent Other,_- 1 ° }}(( From To b 3. Seal Materiel ( Bentoni[e Neat Cement Other '— ) F tip � � - ? • 20 Indicate tote(number of ezlsOng wells onstle v Usl numberof eiri"sling unused wells on s0e = 21 Is this well er arty exlstlng�well or water nthe owner's contiguous roper�rytyveered u-dere ConsumpUVelWater Use Pennit�(CUPIWUP) j or CUPN4VUPApplication7' a Ye ,,; ✓' No Fyes wmpfefe thefollowPng Cl1PIWUP No .'Dlsidd Well ID No 7 '22'Lelduder _ e r - �, s' 23Data Obtained FromGPS jMap Sunreyk Datum_'=NAO 27!•_NAD 83; WGS 641 ' i Itiere6y MYtraietl MBtel¢IYwMIM epplaNa rvbeclTdlefO. FkMeMMmtrWn CEAi. udtlule Wee+ IpAfjP'MlvnNommcrWlhi PORM eW Meb(wmetlan PwaaJe�cWYe,YW NYI n✓m, WriMlarmeMal msnsy WMI YM�44u GenwwOY Wbinal ptmbwmmsnm:rent rNer,Y InetlNMEIesYNNWV✓k]I].RNL aYWn IomJNUN>PWmI'/ehenOm Ws L 1 MyMl.m ) i mubiwtle:L lbrtrrrn6y WlJWumNonprcAOedNW epplmtlme wrueb uq brtl W4etlJn .' Mlaellbrb em rbNNeHbmutlonpwWeOh emve4 mEb tl lur»I fanMMpmw Wtl+Y." i ', �enpyper-0M1emellnr Muµ meb:erbW pw nmeXe.YcppWc hb,lyreabP�ra m9 • WrdWtlb��Ybtl eOa+a dmewrYrbl eOorANM ma aI1W WHDaDawtaJAUTMyru {ontYY VQIbM qNe MWn]a Cage tlfu OwW Y WW oamtrY9 PLL'RatlIAM M1 .% b1A wm Ne �„4a Ptl nWOYw4le0y T%NWtldS yebMdmn�M WAmYtl tYYi4e pnnL f .. OwNmimnl AutlMYJersna. be Pmn ph Nptl NrW:!/,IMWetl L Y A /)�j I 11213 3 //i L02" 4 .. 'slgnetufRq Co1sador" Lkelue No '� i. SItl!reture ofewnerof _ ,t Y __ ,_ _ __.»_v ale. _ : ApP!m'el Greritdtl.BY ~'' "' r ' „C lasue 031e J 3i i- I ENPIIation ate 3V 7-,�HYtlroIDB19l APProvalr ~'+•+ +' sy Fee RecaNed El .- � �� RaealP(Na '' ._ ` ` Chack'NOY _a ' .. yly,l, �. 7 '�• ` }THIS PERMIT I&NOT VAUD UNTIL PROPERLY SIONED BYAN AUTHOR6EOOFFICER OR REPRESENTATIVE OF THE WA1D ORi)ELEGATEDAUTHORITY THE: PERMITSHALLBEAVAIIAeLE AT THE WELL SITE DURING ALL60NSTRUGTION REPAIR MO_OIF{CA71oN OR ABANDONMENT AOTIVITIEs , ,DFP Form B&W2B0a(t) incorparelatlN8253240a(1)FAC. EVeptive Dete Odcbef720103 ", r ti , 1 Paga.t oft t 4. f � � � ° x r `n � b� � �' '� <�� r er t ✓ P� i'4 S :r +' irk q a c " + s +"r r ,� r4 Jy � ✓ p r