HomeMy WebLinkAboutWater Well PermitsMission:
To protect; promote & Improve the health
of all peooein Florida -through Inftrated
state, ooUnty.4community efforts
-
Vigloh:-To be the Realihiest State, In the Nation
'Ron DeSantis
Governor
Scott A. Ri4keest MID
State SUrgeoh General
Florida Department of Health in St. Lucie County
,
Conditions for Issuance of Water Well Permits
Effective July 24, 2017
• Contact the Floridabepartf.rtent of Heal.thin Saint Lucie. County (FDOH —St. Lucie)
prior to consfruQtilng, or abandoning
barldoning'Ohy Well.
a. Call the FDOH — St. Lucie. V11e11, Line at 772-873-4936 or. email
S-LC IM-WELLS10-FI-H EALTH. GOV
b. Provide the following
ing information:
'L Permit number
R. - Driller name
iii, Address,
iv: Date and time.to begin construction/abandonment
• A minimum of 24 hours' notice is .required before constructing any public wafer supply
,9 .. . t. . y
wells. Please call our main office at 772s.8734931 and speak.with Environmental .
Health Staff or provide notification by email to SLCQOH-W-ELLS(CDFLHEALTH. GOV
Submit revisions- to porm 'it andkr site. map within 48 hours of well construction or
, construction
abandonment.
Florida Department of Health -.St Lucie County
Division of Disease control arvd'Health Protection
Bureau of EnvirQnrnental,Health
Location.; 310&8! US HIgIlWayl, Fort Pierce,, FL 34982
Mailing: 5160 NW Milner Drive, . Port St. Lucie, FL 34983
Phone 772=87.34931
Fax 772r585-4 306
Florid,aflealth.gov
Accredited Health Department
Public Health Acc neditafidn'136a'rd
■1
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, 59..307$6
REPAIR, MODIFY, OR ABANDON A WELL Permit No._
C Southwest Florida Unique ID
PLEASE FiLL OUT ALL APPLICABLE 'FIELDS
0 Northwest ('Denotes Required; Fields Where Applicabie)Permit Stipulations Required (Sea Attached)
0 St. Johns River
Soufh Florida Tile water.lyell contractor is responsible for completing
this form and honvardrog the permit applicadoo to the 62-524 Quad No. I)elioeation. No.
0 Suwannee River appmpnate delegated auttiodty where appllcable.
.. s
0 DEP CUPiUVUP Application ,No..
EI Delegated Authority (If Applicable)
1. Y3 Zf s``'Y�Lt
Fa&�Llo9dAMlT•'I►71 T�!!:1'zffi
4.. o . Fot 1 b n _.)
`(S�e-c-bo_ri' or Land t3rarit •Towns ip ange County,
5._�"'�Cf�1PYtC'�'lfPl�YtI`+ll�Y-vf�CP,� -
'State "ZIP "Telephone Number
S
% &0--�— —
Block Unit
if 62-524: Yes
7. •Type of Work: ->L Construction _Repair Modification Abandonment
8.'Number of - Proposed Welts i 'Reason for Repair, Mpdificatlon,orAbandonment
9. 'Specify Intended Use(s) of Well(s): %� D D
4-4
Domestic —Landscape Irrigation Agricultural Irrigation _Site Investigation
Li-ti!
_Bottled Water Supply —Recreation Area Irrigatlon `Livestock _Monitoring
_Public Water Supply (Limited Use/DOH) —Nursery irrigation Test
Public Water Supply (Community or Non-Community/DEP) �Commercl0inndustrial Earth -Coupled Geothermal- JUL L .2 8
Golf Course Irrigation —HVAC Supply
„Class I injection �HVAC Return
Class V Injection: _Recharge ,_.__Cornmercialfindustdal Disposal _Aquifer Storage and Recovery _Drainage DOH iii+$- LUt
Remediation: Recovery AirSparge _Other(oesaiba)___.�__�--,�____._•�_ •_,_ F IR �
_Other (Describe) (Note: Not ali types of wells are permitted by a given permitting authority)
rL
O'Distance from Septic System if s200 ft. 11. FacHtty Description r 12. Estimated Start Date&W�
3,'Estimated Well DepthJ2�E.,ft. 'Estimated Casing Depth •�6ft. 'Primary Casing Diameter I in. Open Hole: From To f{.
4. Estimated Screen Interval: Ffom�a z To ft.
5.'Prlmary Casing Material: Black Steel Galvanized _PVC Stainless Steel
Not Cased Other:
6, Secondary Casing: __Telescope Casing Liner Surface Casing Diameter in.
7: Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
8.•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 (oescrba)
9. Proposed Grouting Interval for the Primary, Sacondaryi and Additional Casing:
From
To .
Seal Material ( _Bentonite�Neat Cement
Other )
From
To
Seal Material (�_Berttonite Neat Cement
Other )
From—To—Seal
romToSeal
Material (__Bentonite Neat Cement
Other )
From
To
Seal Material (_BentonlIe 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 ConsumptiveMater Use Permit (CUP/WUP)
or CUP/WUP Application? � Yes —X,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
thwaby certfy Met I cop MnVy will; are appkatla rile? of Tree 40, Florida AdninlstreNa Coda, and thal a watw
use pomriI or arveuai racharga parMil,.if n4l;Wad, has Lean or wa be alaewd pear to arlimmcamant of avi
"all,that I am No' owner I'll,
era property, net Ina tnromabon provided is 4MMile, aM Ural I am awara Of my
rasptnsidlalas rnd'ar Clwptar V Ralda stall''". to mo'aaain or properly abaMdn ants wag! of, I Certify that I am
cOnO',n¢Dotr. I hrMar earafy Mat all Wornta.en rzavidorl in MIs appket:oh is lim6r a.end that Ivnll!Main
Ina aganl fa Md awriar, that Via Wkinnalion provided Ls accurate, and that I nave brloened Ma cellar 01 Mae
necessary approval Iran Char ledaral, sgl0. ar (prat govert7hran4, Il appiialla. 1'2t�11e to pravld4 a well
can0laPa0 report to" Dtund wthin 30 "after camoct im of Mo conenucurn, repay, rtgd'did%aw, a -
resaara4ntaas am stated obon. 'collar eaubrils to allowing "personnel of bls %WD dr Uelogaled Autnontyaocees
Lathe wee eta during the eonstucaa+, repa+v, modifiwboa, or atarrdaemant atilnori:sd ey Min aennil.
atw4on xnt autrionzn4by Mir perms: m b+e pennd aerrmfbn.wiichaver tint.
-_ 6�►�a�o
'S' na ur ,of Contractor - License No.
-
-- -___ -
' .ignature of Owneror . ' nt D e
Approval Granted By
Fee Received S
Receipt No.
issue
Expiration Date
Check No.
Approval
Iritats
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BYANAUTHORIZED OFFICER OR REPRESENTATIVE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OI
DEP Form: 62-532.900(1) Incorporated in 62-5MA00(1), FA C. Effective Date: October 7, 2010
OR DELEGATED AUTHORITY. THE
Page 1 of 2