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STATE OF FLORIDA-PERMITA PLIGATIQN�TO, CONSTRUCT;
59-30336, ��rG
E REPAIR; MODIFY; OR ABAND di LAMELL Permit No —_ ?i �5F`0
;. of ixr.TiT Flond&Unique lid
f Southwest•
PLEAME-fl LOUTALL-APPLICABLE , �+
' Northwest' (Denote Requirt:d_Fields VNiere:Applicable] Permit Stipulations Required (See Attached) i�O��O o
South'StJoh to dlaer th}s form an forwa%rig the perrnrt applrcatfon to the' 62 524'Q'uad,No: Delineation No
The water // wpfractoris responsbie far@omp/etiri8,
_Suwannee River appmpnate elegatedauthonry;t4he2;appNcable:
CUPNVUPAppllcat}anNo:
Detegateid'Authority,(If,Appiicable
ABOVE THIS LINE FOR OFFICIAL USE ONLY
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'Owner, Legal Nan fCors C ty *State 'z'Telephane:Numberporation Addres- 2. � S? o 2 � v�-.o r✓ � l�.r-.. �-°,�'� �er c° . �L=- 9 �a'1 - ,
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Well.L•ocation =Address_; Road. Name or Number; City,
s li d . S`l � - owl D 601D
'Parcel JD No (PIN)'orAitemate_ Ke (Circle Ohe) tot., Block Unit.
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Section or Land Grant Township•; •Range Court Subdivision
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o/1a1 i'r,S i�.Pl-l.nr fl, 9: 3 (02.3 Jaln3
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Water Well Contractor License u berg , 'Telephone Number ._. E,-mall'Address.
41
'Water We Contra" or's `Address w it! State .ZIP._.. -
7 •Type of Work Construction ` .__Repair: _Modifi ft- d Abi ridonmer t ' D`` D !] -
8 'Number of Proposed MelisT '� Reason for Repair Modtfiaaoon. o me D
9 'Sp ecify.:intended Use(s),of Vtiall(sj• , [5A
Date S2tarrip
r✓_Domestic, Landscapearrigatiori: _Agricultural Irrigation' _Sete inVestlgation O-TVBottled:.11lhaterSupply _RecreaborrArea Imgation=LlVesto_ MbnitoringRPublic WaterSupply(Limited UseIDOH)Nursery,lmgabon Test
R ��20
_Putilio VVater$upply (Community.or NorrGonimunityLDEP—Commercialllndustrial _Earth-Coupied'GeothetTrial .j
Golf Course Imgation HVAC Supply
Class f lnjetxion x _ HVAG;F et�m FG H in St Lude?County
Class U Injection _Recharge' CornmerciaUfndustriai D sposah. Aquifer Storage and Recovery._Dranag�NVl ONMENTAL,HEALT. '
Remedtatton:'_Recovery _Air:Sparge =Other (Des
_.Other (Describer _ (Note; Not:alt typeso►Wells are pertnttted by a:gvven permitting authority) _ 3 Official Use Only
10'Distance feom Septic System .If s 200 ft.- �' ` 11: Facts ty. Description.. ' V ^'� 12. Estimated StartDate
13JEsbmated 1Neli Depth % !>, ft 'Estimated Casing Depth ft Primary Casing Diameter �% in: Open Hale: From To ft.
14 Estirated Sueen'Interval: From To .. • :ft` `
15?Primary C' ing.Matenal Black Steel alvanized PVC Stainless. Steel
17
- Not Cased' er. =
16 Secondarytasing . __ _Telescope Casing,, Liner, Surface Casing Diameter . m.
i
!T Sbdbndary-Casing°Matenai:, Black Steel' Gal anrzed:_�P-VC', _ Stainless;Steel ,-` Other.
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18:�Method.of Construction Repair, or Abandonment - uger: , ✓Cable Tool Jetted Rotary' Sonic.
A Cembinabo_ n:(Two.or More Me�odsj; Hand ntieii(Neii Point Sand<Roint) Hytiraullc:P_oint (Direct Pugh)
l oriiontal Drilling Plugged byApproved,the odv Other (Di4oriber _
19: Propased'Groutii Interval for the Primary, Secondary, and Addttionai Casing: ;
. From 7o SealMateriah(. Bentanite' Neat Cement';- ' Other F
From . `. To ' _ ' _ Seal'Material ( Bentonite Neat'Cemenf, Other
From` to ,' Sealmatedal (, Bentonite. . ' Neat Cement Other"' _ )
From To SeM.Material'`L_Bentonite .. Neat-Cemi:nt' . _Other, )
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20. lndicate total number, f eidsting wells on site , �' - ' List number of Existing unused wells on site
21:'Is this weli'or any extstrng well orwater withdrawal on the o; er's cont*dus.property covered under a ConsumptiveNVater Use Permit (CUP/V11UP);
j
orCUP/VWP Application? YesF No-: If yes co plete;thefgllowi CUOAVUP No,, District Well ID No.
' 22:,Latltude. F
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- Longitude - •_ • • •,
23: pate Obtained From:' : GRS Map, Suave) Datum NAD 27 tdAD 83' - WGS tl4
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t hereby eer[try,th.-t'ItMlt ccmpy wan theYapptsabie rules Drams'ao,Pmnoa'Atlmtmttnhcn Cbd4/- mataw�ter {:I gerMy �:a{:tim the amirptthe propeat the nroreation acindeda aaurate, ahp inat l an! awue:c •ry
';+sa prnne:or orOGpai redittrpe pxrtnR`�}haedcd'has Been or`wa he otsamed pnorto Cermmenuma otwahu resparibtroes trade. Chipier 3i3.HondaStatutes to maintain rn WcOarlyabandon ms well ar.deing:tnit ::an
camauNon IturlherCenRy that an eircrinstmit provided n this-appiiabdn a accurate and Um I wm bta+G_ ; ' '.the apertt ibr late iwirw that Itie':raannabCnprovtlad a acx; nMe, and thi t I hiVG,nrCrM6 hie •*Tier-a1 hie
necessad apprdtq+ttall tahlr iedenl Wte' Gr fetal paverrueenl§, if aoW cable l apreeto provide i WerresportsibM aria ve, 0umefoomenta to alloVnrg pe connN or the WM� d•,Jelr reo A � crry access a
ax},�Jepon npdRto tni0strrm wmfi30 days aharmmpahon,oitne�naruetion tepav mad fat; or. the wall Cl ;Me eo_ n,r ',modienhori arahandor—art atiftmea bycma or.", -
aWtrlonm- a¢eq,trj VRperna;: cr the tx•m6;eapu8aan �vfirctievar oocur7:tin' -
•5rr ure of Contractor .a _ _- _, _ _ 'Lfcerise N _' °` ., ' of Owner _Agent
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Appro% Grair 4121y Issue Date % q Expiration Date Hydrologist Approval
Fee Received S', _Receipt No. ChLeck No'. .
;THIS PERMIT:IS:NOTVALID UNTILPROPERLY SIGNED t3Y AN A ORIZED OFFICER OR REPRESEyTATIVE OF THE WMDVOR,DELEGATED AUTNORITI'`. HE
PERMIT SHAIX AVAILABLEAT THE wELL SITE DURING ALL' CO . STRUGTION, REPAIR; MODIFICATION 'b 6-ANDONMENT ACTT ' ITIES
FORM LEGR'Ogmot t(eHOj Thts;permk is. ali�for 80 days from the date of tsaua Rule
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