HomeMy WebLinkAboutWater Well PermitsSantis
Mission: ,; Ron DeGovemor
p,,�.
To protect, promote & improve the health -
of all people In Florida through integrated
state, county & community efforts. I` ` Scott A. Rivkees, MD
HFA State Surgeon General
Vision: To be the Healthiest State in the Nation
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 (cr�.FLHEALTH.GOV
b. Provide the following information:
i. Permit number
ii. Driller name
iii. Address
i.v. 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 SLCD_OH-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 Hlghvvay1, Fort Pierce, FL 34982
Mailing: 6150 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
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Water Well Conlr
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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, 59-30872
REPAIR, MODIFY, OR ABANDON A WELL Permit No.—
❑Southwest PLEASE FILL OUT ALLAPPLICABLE FIELDS Florida Unique ID,_
❑ Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required (Sao Attached)
❑ St. Johns River
'South Florida The water well cantrsfc(or /s responsible lorcompleang
this form and forwarding the permit application to the 62-524 Quad No. Delineation No.
Suwannee River appropriate delegated authority where applicable.
❑ DEP
• Delegated Authority (If Applicable)
or
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*County_,,...AS uab di
irQ�S'� i t?�i��
CUPIWUP Applicatlon
fL ><3 1S4-')i36-44ly'
'Stale ZIP 'Telephone Number
ao 1 laic)
I )apt 1 Block Unit
Check if 62-524: Yes ,� No
E-mail Address
State
7. Type of Work:,_, Construction _Repair _Modification Abandonment
8. 'Number of Proposed Wells _I 'Ronson for Rapalr, Modification. orAbandonmonl
9. -Specify Intended Use(s) of Well(s): D i
,Domestic _Landscape Irrigation _Agricultural Irrigation _Site Investigation
_Bottled Water Supply `Recreation Area Irrigation Livestock _Monitoring
_Public Water Supply (Limited Use/DOH) —Nursery Irrigation _Test
Commercial/industrial _Earth -Coupled Geothermal JU L 2 8 2020
_Public Water Supply (Community or Non-Community/DEP) --Golf Course Irrigation _HVAC Supply
Class I Injection _HVAC Return
Class V Injection: _Recharge Commercial/industrial Disposal _Aquifer Storage and Recovery _Drainage OH in St Lucie. Coun
Remediation: Recovery _Air Sparge _Other anscribe)
_Other (Describe) (Note: Not all types of wells are permitted by a given permitting authority)
10.'Distance from Septic System if �200 ft. 11. Facility Description t 12, Estimated Start Date ASAP
13.'Estimated Well Deplhl _2,6_ft. 'Estimated Casing Depth $ ft. 'Primary Casing Diameter Qin. Open Hole: From —To ft.
14. Estimated Screen Interval: From_ 06 To_IZ-5.ft.
15.-Primary Casing Material: Black Steel Galvanized ,,,, _PVC Stainless Steel
Not Cased Other:
15. Secondary Casing: _Telescope Casing. Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
18.4Method of Construction, Repair, orAbandonmenl 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 (Doscrlbo)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From To Seal Material (__Bentonite_)e Neat Cement Other )
From TO Seal Material (Bentonite Neat Cement Other )
From To Seal Material ( Bentonite Neat Cement Other )
From -To --Seal Material (__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 orwater withdrawal on the owner's contiguous properly covered under a Consumptive/Water Use Permil (CUP/WUP)
or CUPMUP Application? Yes _,No If yes, complete the following: CUP/WUP No. District Well ID No.
22. Latitude Longitude
23. Data Obtained From: GPS _Map Survey Datum: NAD 27 NAD 83 WGS 84
I heruoy certify Nat I WP comply w4q Itiu 4p11tratle Ades of Tee 40. FlandvAdntnUVd1n 0 Code, and Mat a watrr I Cofliy that I am me o"Of of the property, Ina1 IhY vllflrn=01 prcvblwl a M=X416, afd 11.11 Antawam of my
use pamd of adieoat recharge patina If needed, hoe bean orwti ba tbuinad prior to mrnmantBinwd of web rdspmmbatas trtdar CnapWr 373. Ficrda Stamt..10 msnt" a properly abandon this wall: or, I canify INN I am
cenetrvicean. I lwmer cerLy mat elf,n(ormanon pforvlM m hl:d appotatwn is acwmla erld mat l w21 ohmm [no agent for Ine otmtr, ttlat e,0lldormman provided Is acii,rale, end that I tare informed ttd owi+w 0t lheu
necessary aporoval tram other fedafal, stale, or local gOVemmards, itappftcahla. I agree to 0ov'do a wad meponr0,ldles is stat■d above. Oanar eonsanta IoaUrWnp par*wvw of tide WMDor DaVgalod AUlnonfy atsasa
Complabon Nowt to Na Wae,ct Adh,n 70 ddya after Con,01"ori of fee condtuCawt. fop&. n10dG44on. or to the woe ale d"g the CdnsUUcson. repo+. moddwUon, or 4113044C „Mt dueWUW 01aea pernlll.
obandon%%rd aulneriaad by irm paint. or me fMfmil "ration. whlrh of myrs arti.
'Signature of Owner a Ago a F 'Date
Approval Granted By w-'*`�� Issue Date �' Expiration Date f� rT�FlydrologistApproval
1 i loiaa.
Fee Received $ Receipt No. . Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENTACTIVITIES.
ID
DEP Form: 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October 7, 2010 Page 1 of 2
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LEGAL. DESCRIPTION',
LOT 20, BLOCK 160, LAKEWOOD PARK UNIT
NO. 12, ACCORDING TO THE MAP OR PLAT
THEREOF AS RECORDED IN PLAT BOOK 11.1
PAGE 26, PUBLIC RECORDS OF SAINT L•UCIE
COUNTY, FLORIDA.
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LAND CLEAHING fftll'ti:
A) ALL NON-NATIVE AND INVASIVE VEGET
FND 3"x3" CONCRETE MONUMENT WILL BE CLEARED.
B) NO PRESENCE OF ON -SITE WETLANDS.
— C) NATIVES/PINES ADJACENT TO THE PRC
WELL POINT AREAS WILL BE SAVED.
D) NO CONSTRUCTION BARRICADES WILL E
p j E) A HEAVY DUTY REINFORCED SILT FENC
FABRIC TO BE INSTALLED AS PER MANUFAC
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BLOCK 160 PROPOSED SEPTIC
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r St. Lucie County Health Department
HEALTH 5150 NW .Milner DrPort Saint Lucie, FL 34983
PAYING ON: #: 56-SF-21.09584 BILL DOC.m56-BID-4774806 CONSTRUCTION APPLICATION #: AP1525822
RECEIVED FROM: Pedro Quiiada AMOUNT PAID: 1660.00
PAYMENT FORM: CHECK 1030 and 1.031 PAYMENT DATE: 07/15/2020
MAIL TO: (434 21st Street. LLC)
FACILITY NAME: Su-mkI rye lCVOQ:OCD p
PROPERTY LOCATION:
5504 Deleon Ave
Fort. Pierce, FL 34951
13 Lot: Block: 160
Property ID: 1301.61-401030004
EXPLANATION or DESCRIPTION:
QUANTITY
FEE
128 - OSTDS Construction System Inspection Research Fee
1
$
5.00
-1 - Surcharge (All)
1
$
45.00
-1 - OSTDS New Permit Surcharge
1
$
10.0.00
-1 - OSTDS Construction Application and Plan Review,New
1
$
100:00
123 - OSTDS Construction Slte Evaluation
1
$
115.00
12.6 - 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
A - Well Construction
1
$
115.00
RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-4502539