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Home My WebLink AboutWater Well PermitRAF $F- 71.110,555> STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, OR ABANDON A WELL Southwest PLEASE FILL OUTALLAPPLICABLE FIELDS y. f `• _Northwest (`Denotes Required Fields Where Applicable) s n D St. Johns River { a . •� y • The water well contractor is responsible for completing l South Florida t this form and forwarding the permit application, to the Suwannee River appropriate delegated authority where applicable. DEP Delegated Authority (If Applicable) 62-524 Quad No. Delineation No. CUPfWUP Application No. A V AL ,& l/-40 CX 4UM46 cc` r-� 'Owner, Legal Name-IfCorporatiorr- 'Address t-City State .'ZIP Telephone Number *Well Location -Address, Road Name or Number, City 3..3g1 -3- 8�t3r--c�Gs"7 -tea- I *Parcel ID No. (PIN) orAltemate Key (Circle One) 15� Lot Block Unit 4. 03 % S W 1: t4c lte `Section or Land Grant 'Township 'Range Coun Subdivision Check if 62-524: Yes No — — 5.,J as , L2_onal r,JS Ltiel/ flr:)[,=� A63 623 920 `Water Well Contractor License 4mber 'Telephone Number E-mail Address 6. rj-7a�-f_ pl LBtn,[ Qkg,-chnh4`� PL 3� 'Water We I Contractor's Address itv State ZIP 7. *Type ofVVoric:,/Construction _Repair —Modification _Abandonment 8. ' Number of Proposed Walls F 'Reason for Repair, Modification. or Abandonment 9. *Specify Intended Use(s) of V%11(s): /A\ 0 t L/ Domestic, —Landscape Irrigation _Agricultural Irrigation _Site Investigation _Bottled Water Supply _Recreation Area Irrigation _Livestock Monitoring _Public Water Supply (Limited Use/DOH) —Nursery Irrigation Test _Public Water Supply (Community or NorrCommunitylDEP)—Golf —Earth-Coupled Geothermal A U G 18 2020 —Golf Course Irrigation HVAC Supply Class 1 Injection HVAC Return Class V Injection: —Recharge—CommerclaVindustrial Disposal Aquifer Storage and Recovery _Drainage Remediation: —Recovery _Air Sparge _Other (Describe) DOH in St Lude Cot _Other (Describe) (Note: Not all types swells are permitted by a given permitting authority) VIRCMENTA L HEI 10'Distance from Septic System 'ifs 200 ft.l -7T 11. Facility Description IV, 12. Estimated Start Date 1WEstimated Well DepthqO_ft. -Estimated Casing Depth _OLft. 'Primary Casing Diameter in. Open Hole: From To ft. 14. Estimated Screen Interval: From 43 To $'eft. 15 `Primary Casing Material: Black Steel Galvanized PVC Stainless Steel Not Cased Other: 16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter `Z_ in. 17. Secondary Casing Material: Black Steel - Galvanized VPVC Stainless Steel Other 18'Method 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 (Describe) 19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing: From C� Tc Seal Material L__Bentonite Neat Cement Other ) From To Seal Material (_Bentonite Neat Cement Other ) From Tc Seal Material L_Bentonite Neat Cement Other ) From —TO Seal Material L_Bentonite Neat Cement Other ) 20. Indicate total number of existing wells on site List number of existing unused wells on site 21 'Is this well or any existing well or water withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUPNW P) or CUP/WUP Application? Yes No If yes, complete the following: CUPIWUP No. District Well ID No. 22. Latitude Longitude 23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84 1 hereby Cerny that I will comply wad me applcabie rules or Tale 40. Florida Adrmmstrdtiar. Coca and a:at a water I rimy that I am the owner of the property. that the information crowded is accurate. and mat I am aware of my use permit or arbfiam recharge permd. if needed, has been or will he Obtained prior to commencement of well responsibilities under Chapter 313, Florida Salutes, to maintain or properly abandon this well. or. i mrtiy that i am construction f Miser certify that all information provided In this apytration is accurate and that I will obtain the agent for me owner. that the information provided is accurate. and that I have informed me =wrier of no; necessary approvai from ether federal• state. or local govemmexls. If applicable l agree to pr"e a welt rrsponsi ximes as stated above. Owner tsrrems?o allOesrlg personnel of ths MAD or Delegaled Autner¢y access to completpn report to the District wnhln 30 days after completion of the construction• repa¢ modification or me well site me constr� . i ir, n�or., cr abandonment authorized by des oe .4t abandonmer�.aumor¢ed by this permit. cr!he oermir expiration whichever occurs first // 6 *License No. Approval Granted By Issue Date kZ Expiration Dail Fee Received $ Receipt No.. I Check No. a ate Approval inntais THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE I PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES. FORM LEG-R.040.01 (6/10) This permit is valid for 90 days from the date of issue. Rule 40D-3:101 (1), F.A.C. TH Ron DeSantis Mission: ;`j5 S teak Governor To protect, promote & improve the health Y i �r of all people in Florida through integrated state, county & community efforts. �� 6 Scott A. Rivkees, MD HEALTHState Surgeon General Vision: To be the Healthiest State in the Nation RECEIVED Florida Department of Health in St. Lucie CountyuG 2 4N70 Conditions for Issuance of Water Well Permit$njltting Department St, Lucie CountN 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 SLCDOH-WELLSCa,FLHEALTH.GOV b. Provide the following information: i. Permit number ii. Driller name 4 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 SLCDO H-WELLS(a), FLH EALTH. GOV • Submit revisions to permit and/or site map within 48 hours of well construction or abandonment. Florida Department of Health -St Lucie County Division of Disease Control and Health Protection Bureau of Environmental Health Location: 3866 S US Highway1, Fort Pierce, FL 34982 Mailing: 5160 NW Milner Drive, Port St. Lucie, FL 34983 Phone 772-873-4931 Fax 772-595-1306 inAccredited Health Department Public Health Accreditation Board FloridaHealth.gov PAYING ON: RECEIVED FROM PAYMENT FORM: St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 #: 56-SF-2110355 BILL DOC #:56-BID-4778420 CONSTRUCTION APPLICATION #: AP1526397 Alexander J. Piazza PSM, Inc AMOUNT PAID: $ 660.00 CHECK 103 PAYMENT DATE: 07/17/2020 MAIL TO: (The Outdoors Quality, LLC) FACILITY NAME: PROPERTY LOCATION: TBD Melton Dr Fort Pierce, FL 34982 Lot: 17 & 18 Block: 3 Property ID: 3403-805-0057-000-1 EXPLANATION or DESCRIPTION: 128 - OSTDS Construction System Inspection Research Fee -1 - Surcharge (All) -1 - OSTDS New Permit Surcharge -1 - OSTDS Construction Application and Plan Review,New 123 - OSTDS Construction Site Evaluation 126 - OSTDS Construction Permit (New or Mod, Amendment) 127 - OSTDS Construction System Inspection 133 - OSTDS Construction Reinspection -1 - Well Construction RECEIVED BY: VanceMH Note: Well 59-30874 QUANTITY FEE 1 $ 5.00 1 $ 45.00 1 $ 100.00 1 $ 100.00 1 $ 115.00 1 $ 55.00 1 $ 75.00 1 $ 50.00 1 $ 115.00 AUDIT CONTROL NO. 56-PID-4504725