HomeMy WebLinkAboutWater Permit ApplicationSTATE OF I:.. IDA PERMIT'APPLICATION,TO.CONSTRU.CTP='-59'-29765
REPAIR, M( fr Q ABANDON A'WELL mill No.-: -:---
Vogt nisouthwest rlorida Unique 10
T u� U Norfhwest- PLEASE RegTAL d Fields
Where
AP ) hod)
Donotes Re uued Fields Where Applicable) Permit Stipulations Required (Sao Attu
0 St. Johns River �-
Tt1ewater%yellcontractol is responsible forcomp(enng —
)(South Florida this farm and forwarding trio permit Appttcatfoe to the fi2.524 Quad No. _ Dolinafilio No
❑Suwannee°River epproprlatedelagiliodauthoritywhereapplicable.
�" • ❑DEP CUPlWUPApplication 'No—
' 0 Delegated Authority' If Applicable) _ • '
1'.�-•L--L- late ` IP lei phone Number
er gal me. Corpor or ' ddre'ss. 'City
`Well LocaRon -Ad ess, RoacJ Nate a or Nu ber, Cit
3. Lot Block Unit
'Parcel ID -No. (—PIN) or temate e,y C rcle ne) C.r `
�t.. �_ --Cif Bieck2-5 4: Yes f� No
i4. �_ _ - _ —
•S lion or Land.Gtant ship To �/J 1 / I bddiviis'o I
wa r vven CAonrac
'Wa er ellr's�Addres��
7. 'Type of Work: --%Z construction Re
8, 'Number of Proposed Wells
9. 'Specify Intended Use(s) of Welt(s)t
Domestic .2!�_Landscal
Bottled.WaterSupply ___ Recreatk
`PublIcWater Supply (Limited'Use/DOH)
Public Water Supply (Community or Nor
_Class I Injection
Classy Injection: —Recharge _Comm
Remediation: _Recovery Air Sparg
_ Iher tooscrioe) _
10.'Distance from Septic System if s200 fL
13'Estimated Well Depth lfC. 'Estima
14. Estimated Screen Interval. From MT<
15.'Primary Casing, Material: - _ 131ack
Not.C1
16. Secondary Casing: _Telescope Casi
17, Second&yCasing Material.• ' Black
18.11viethad of Construction, Repair, or.Aband
Combination (Two or More,Methoi
—Horizontal Drilling? Plugger
19. Proposed± routing I tervat for the Primar
From To +J Seal Materialt
_ •`, _<Frorn -_ To _ _ _Seal MatenaL'(_-
Prom= To, `Seal Material (_
From_.To . Seal Material (_
20: Indicate total number of existing wells on s
21.AIs this well or any existing well orwater wit
or CUPlWUP Application? Yes ti
22.LLatitud'e ,/
23. Data Obtained From: GPS �n
uWatil ban other (w6fal, eta%, to foci 0"W"a 's. a
..flint la 1.
at wa within 30 din after oanalwlonof ow
r, - f
Approval Granted By
;Fee Recelved b'
'THIS PERMIT IS NOT VALID UNTIL PROPERLY
',PERMIT SHALL BE ANAILABLEAT THE WELL S
DEP Farm 62-532.900(1) Incorporated in 62-5&
- city
Modification Abandonment'
- - •Reaeorr for Ropnlr, Modlr.—ca nn, or bandonrnont
hate Stamp
Agation`'` _Agricultural Irrigation _Site Investigation 1 7 201+y
rea Irrigation _Livestock _Monitoring J J
^Nursery rrigation° Test,
I
_Commercial/industrial Earth -Coupled Geothermal
mmUnity/DEP) Golf Course Irrigation _HVAC Supply FDOH th °S t LUCfie Cou*
_HVAC Return ENVAC NM ENTALHEALTH
al/Industrial Disposal Aquifer Storage and Recovery�_Drainage
_Other i0escdboi . Official Use Only
Not ytins of wall - nrmiaad_ by a,ruivan porntiRU6ST authority)
11. Facili Description 12. Estimated Start Date
Casing.Depihff, 'Primry Casing;Diamelerin: Open Hole: F _
.12
ft. ,
31 _ Galvanized �UC _�Stainless'Steal
t Other
Liner Surface Casing, Diameter in.
el ' Galvt nized PVC Staintess Steel ther
rent: Auger Cable Toot _Jetted, Rotary Son
Hand Driven (Well Point, Sand Point) Hydraulid Point (Direct Push
Approved Method _Other (Deecrltw) -- ___--
acondary, and AcJdRional Casing:
Bentonite, Neat Cement Other ) 1
List number of unused wells on site
lval on the owner's contiguous property covered under ConsumptiveNVater Use F ermit(CUP/WUP)
o if yes, complete the following: CUP/WUP No,__._District Well 10 No:,
Ilude
Survey Datum: NAD 27 NAD 83 GS 84
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ptnr In atmmeMemenr'nr.wn. _ rn+{iom2:+4ws wWar.Cn�pl+rJ)l, ikNnn Slawtn0. to mwtlnl�or MnMAr� alnvhl•, v,l umW.7ullarn
;nlmu and Gla{ 1 wdI W4lhl tiw open) to! IAo owrM„ Ihatlho uVtrrroCarp(a,rlad .a arcuroie. ant ln]I 1 na mfomaid ina owlwr or rote
Lim Me or WAod.Au'hwlly UMM
o.=
Issue Dalo:J !%Ik� Expiration Date 111� Hydrologist Approval
Ir uA's
Receipt No. _ Chock No.
BYAN AUTHORIZED OFFICER ORREPRESENTATIVEOF THE WMD OR DELEGAT 'AUTHORITY. THE
ING ALL CONSTRUCTION; REPAIR, MODIFICATION, OR ABANDONMENTACTIVITIE
F,A.C.' Effective Data: October 7, 2010 Pago 1 of 2,