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Home My WebLink AboutWater Well Permitk . a Ron DeSantis Mission: Governor To protect, promote &improve the health r_ .vu of all people in Florida through integratedWIRstate, county & community efforts. Scott A. Rivkees, MD HEALTH11 kklk State Surgeon General FO Vision: To be the Healthiest State in the Nation c°1 t eat 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 SLCDOH-WELLS(a)-FLHEALTH.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-WELLS &,FLHEALTH.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: 3855 S US Highwayl, Fort Pierce, FL 34982 Mailing: 5150 NW Milner Drive, Port St. Lucie, FL 34983 Phone 772-873-4931 Fax 772-595-1306 Accredited Health Department Public Health Accreditation Board FloridaHealth.gov T`O�rttr �r'�rr f E, GD 1FF'�;i _l 'APSr-- z�i STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, 59-30875 REPAIR, MODIFY, OR ABANDON A WELL Permit No_ Southwest PLEASE FILL OUTALLAPPLICABLE FIELDS Northwest ('Denotes Required Fields Where Applicable) J St. Johns River The water well contractor is responsible for completing South Florida this form and forwarding the permit application to the Suwannee River appropriate delegated authority where applicable. DEP Delegated Authority (If Applicable) Unique ID Stipulations Required (See Attached) 62-524 Quad No. Delineation No. CUP/UWP Application No. 1. EL." Z A K A la & I-) l<10 ..n 0 na LIr PT- f Or fL -3 -a .;)72 <-//jK-e-C " 'Owner. Legal Name,ifCorporatiarr"Address- `City 'State `Telephone Number 2. Ti3 D Mai( i A-,&, _'ZIP `Well Location -Address, Road Name or Number, City 3. '340 s - &0! —43a-5 4 -5- 'Parcel ID No. (PIN) orAltemate Key (Circe One) Lot Block Unit 4. 03 ,%S o& `Section or Land Grant Township Range Coun Subdivision Check Chk if62-524: Yes No — — 5.c3an � Le_D/ndtt,r�S lti>?rl pr:ll,- � �63 6R3 920 'Water Well Contractor License Zmber 'Telephone Number E-mail Address 6. . 7a C�c" e g _ fh L &,A•e k eQ c st n b P-L Water We II Contractor's Address citv State ZIP 7. 'Type of Work: Construction _Repair —Modification _ Abandonment 8. • Number of Proposed VWls I -Reason for Repair, Modification, or Abandonment ID9.'Specify Intended Use(s) of Wall(s): Domestic Landscape Irrigation Agricultural Irrigation _Site Investigation [ram _Bottled Water Supply _Recreation Area Irrigation —Livestock Monitoring _Public Water Supply (Limited Use/DOH) —Nursery Irrigation Test Mtn —Public Water Supply (Community or Non-Community/DEP)—CommerciaUlndustrial —Earth-Coupled Geothermal AUG 1 8 2000 _Golf Course Irrigation HVAC Supply Class 1 Injection HVAC Return Class V Injection: —Recharge—CommerctaYindustrial Disposal Aquifer Storage and Recovery —Drainage Remediation: —Recovery —Air Sparge —Other (Describe) DOH in St Lucie Coui ity (Describe)tE VIRONUMN04H TH Oche( (Describe) (Note: Not all types of wells are permitted by a given pennilting authority) 1 WDistance from Septic System ifs 200 ft. t7!�- 11. Facility Description S r 9- 12. Estimated Start Date 1WEstimated Well Depth_96ft. -Estimated Casing Depth• G3 fL -primary Casing Diameter 2- in. Open Hole: From To fL 14. Estimated Screen Interval: From- L-L-To-aC-ft. 15'Pdmary Casing Material: Black Steel—L/Gaivanized PVC Stainless Steel Not Cased Other. 16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in. 17. Secondary Casing Material: Black Steel Galvanized ,5PV� Stainless Steel Other 18 -Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted Rotary Sonic Combination (Two or More Methods) Hand Driven (Mil 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 TO Seal Material L_Bentonite Neat Cement Other ) From To Seal Material L_ 136ntonite Neat Cement Other ) From To Seal Material L__Bentonite Neat Cement Other ) From TO Seal Material L_Bentonde Neat Cement Other ) 20. Indicate total number of existing wells on site List number of existing unused wells on site 1 'Is this well or any existing well or water withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) or CUPNVUP Application? Yes No If yes, complete the following: CUPMNP No. District Well ID No. 22. Latitude Longitude 23. Data Obtained From: GPS Map _Survey 1 hereby cenrify that I will comply win the arplic2 ie rules of Tate 40. Florida Administration Code and= a mcer cse permit or artifiaa, recharge pamR if needed. has been or wit be obtained prior to comm encemem of well construction I further outify matae information provided in this application is aeaaate and that twit clan necessary appravai Tom o6`,er fdML state. ar tool govemmeos. d appeoble' t agree to prawde a veil amplebon reponte the Dctritew th n 3a pays arter competion of the consbcction. repam modification or abandonm or¢d by the permit or the bem It expeation whichever occtas fist // 6 *Slaoifffure of Contmdor 11-1cense No. Approval Granted By Issue Date Fee Received S Receipt No. Datum: NAD 27 NAD 83 WGS 84 1=rely mat I am the owner of the property, that me mronrahon Provided is acarate, one mat i am aware of my responsibilities under Chapter 37Z Ronda statutes, to maintain or property abandon this well. err. i ce.* inat ; am ate agentfor fie owner. that the mkmhaeon prevdd is acsmate. and that 1 have into.", ed me: .,er of his respo sidlates as stated above. Owiler.conserlm to allmrig personnel of cos •NMD or Delegated Ar.•mamy access to me well sire main g the yMM'Strirt.r"brh epa'v, rrgietficabor., cc abardxmem authorized by cos x"r ration Date Check No. 2G ate meals I 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 (6110) This permit is valid for 90 (Jays from the date of issue. Rule 4oD-3.101 (1), F.A.C. S a�' Af� wcy a- G(i I- ='' r°"= St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 HEALTH BAYING ON: #: 56-SF-2110358 BILL Doc #:56-BID-4778428 CONSTRUCTION APPLICATION #: AP1526400 RECEIVED FROM: Alexander J Piazza AMOUNT PAID: $ 660.00 PAYMENT FORM: 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: 19 & 20 Block: 3 Properly ID: 3403-805-0059-000-5 EXPLANATION or DESCRIPTION: QUANTITY FEE 128 - OSTDS Construction System Inspection Research Fee 1 $ 5.00 A.- Surcharge (All) 1 $ 45.00 -1 - OSTDS New Permit Surcharge 1 $ 100.00 -1 - OSTDS Construction Application and Plan Review,New 1 $ 100.00 123 - OSTDS Construction Site Evaluation 1 $ 115.00 126 - OSTDS Construction Permit (New or Mod, Amendment) 1 $ 55.00 127 - OSTDS Construction System Inspection 1 $ 75.00 133 - OSTDS Construction Reinspection 1 $ 50.00 -1 - Well Construction 1 $ 115.00 RECEIVED BY: EvansJS AUDIT CONTROL NO. 56-PID-4504729