HomeMy WebLinkAboutwellMission:
To proled, promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
Hh LTH
Vision: To be the Healthiest State in the Nation
Ron DeSantis
Governor
Scott A. Rhrkees, MD
State Surgeon General
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.
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
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-WELLSCu)FLHEALTH.GOV
• Submit revisions to permit and/or site map and associated fee within 48 hours of well
construction or abandonment.
Florida Department of Health
St. Lucie County Accredited Health Department
5150 NW Milner Drive • Port Sl. Lucie, FL 34983 Public Health Accreditation Board
PHONE: 7721462-3800 - FAX: 7721871-5360 01
StLucieCou ntyHea ith.com
PA..vnrvn rcti APPLICATION TO CONSTRUCT,
RE IR, MODIFY, OR ABANDON A WELL
Southwest
Ll Northwest PLEASE FILL OUT ALL APPLICABLE FIELDS
Denotes Required Fields Where Applicable)
0 St. Johns River (`
El South Florida Thewaterwen contractor(sresponslbleforcompleting
ESuwanneeRiver hrs/onnand/o wardingtheyernitapPrlmtionmthe
❑DEP aPProyr/atedelegatedanthority he.. oypllcoble.
❑ Delegated Authority (If Applicable)
"Well Loc Ion -Address, Road Name or Number, City
3. 2 -1 U -5- - C60. - - 600- t
Parcel ID No. (PIN) or Alternate Ke CI
nit No.
Ida Unique ID 59-31041
lilt Stipulations Required (See Attached)
24 Quad No. Delineation No.
N UP Application No.
State ZIP Telephone Number
4 `� Y (, rcla One)
Section or Land Grant"Tot Township hip Ran a Block
"1 �* a Lot Unit
5.:-\�t-- `1'I'll`V'aY'dl.�t'vtlrhi�l4„9. Ill county cN
Subdivision-, Check if 62.524:❑ Yes [I No
6. --) I(1`,) 1 `4, Q,14N
vvater Wall Contractor's Address do \L'- 4 t
7. "Type of Work: X Construction ❑ Repair ❑ Modification[] Abandonment City
8. 'Number of Proposed Wells _;--
9. "Specify Intended Use(s) of Wallis):
Domestic[]Landscape Irrigation
Bottled Water Supply Recreation Area Irrigation
Public Water Limited Use/DOH)
Public Water Supply y (( Com unity or Non-Commity/DEP)
ur ❑
] Class I Injection ❑
a
lass V Injectio • ❑
'Reason for Repair,.
Agricultural Irrigation D Site Investigations
Livestock Monitoring
Nursery Irrigation Test
CommerciaUlndustrial Earth -Coupled Geothermal SEP 2 1 2020
Golf Course Irrigation HVAC Supply
n Recharge [] Commercial/Industrial Disposal HVAC Return
Remediation: Recove p LJ Storage and RecoveryE] Drainage OH (n St Lucie Count
❑ ry ❑ Air Sparge ❑Other (Describe) E IRONMENTAL HEAL'
❑ Other (Dasuibe) - ORicial use Onl
'10."Distance from Septic System If 5 200 ft,111. Facilit Description
13.'Estimated Well Depth ,ft. '"Estimated Casing Depth h} g, primary Casing Diameter _in.OpenHole: Start -To
14. Estimated Screen Interval; FrOmr r __ft,
To �0 t- i A.
15 "primary Casing Material: Black Steel
yOther: nizad PVC Stainless Steel
Not Cased Other:
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter
17. Secondary CasingMaterial: Black Steel Galvanized P(, PVC Stainless Steel in.
18.'Method of Construction, Repair, or Abandonment: Auger Other
Combination (Two or More Methods 9 X Cable Tool Jetted Rotary Sonic
Horizontal Drilling) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push)
Plugged by Approved Method Other Waeuibo>
19. Propose Grouting Ipterval for the Primary, Secondary, and Additional Casing:
From To -� Seal Materia( Bentonite
From To (+� Neat Cement Other -
Seal Material ( Bentonite Neat Cement Other
Froin
From To Seal Material ( Bentonite Neat Cement Other
To Seal Material ( Bentonite Neat Cement Other )
20. Indicate total number of existing Wells on site)
List number of existing unused wells onsite
21.11s this well or any existingg well or water withdrawal on the owner's contiguous props rtyy covered under a Consumptive/Water Use Permit (CUPNVUP)
or CUP/WUP Application? Yes No If yes, complete the following: C%/WUP No.
22. Latitude Longitude District Well ID No.
23. Data Obtained From:
Ihb.becmn,bI,— ---..-......
Approval Granted By
Fee Received $
GPS Map
Survey Datum: NAD 27 _NAD 83 _WG5 84
,Iraliva Cotlo, end iofl.ff lm ICodify 14Bll am the ownarofth. propody,lhel the"d000b". proWded la a..amdGS lheilam aware of my
to c.mmoet I WlJllowell maponslbAlloB nod -1 Clmpim 373. Model. elahthte to melnleln oWkidd 1IW-dy oreae aadWed; aq l..or.11latlam
ale and NellwN oblaN the agent for the ownog ihei the i.lormulmn proWdad
be --W lbalineve inbrmetl 0e awue,oly111.
greo to proWtle swell asponaibddioa es sleretl above. Ownordoneenk to abowin the fee
epei. metligeall.n, er to ills Well she during the.o.alnnllan,lepeif.m.tlillcat oe, Or ebemlo MeF 1111. wiodrlezed bylo,,,edirtAuthonty access
Bl.
hht
3Cr _ �s-Zayo
`License No. gnature of Owner or Agent
a . ,.. - 'Date
Issue Date 7 Z/ ?-I Expiration Date 3/z7 ya2n Hydrologist Approval
Race! t N
rHS p o' Check No. mnlais
PERMIT SHAT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE MO OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE qT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, E ABANDONMENT ACTIVITIES.
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HEALTH
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
PAYING ON: a: 13ILLDOG n:56 -BID -4980980
RECEIVED FROM: J & J Leonards Well Drillinq AMOUNT PAID: $ 230.00
PAYMENT FORM: CREDIT CARD 000107 PAYMENT DATE: 09/09/2020
MAIL TO: J & J Leonards Well Drilling
Okeechobee FL 34974
FACILITY NAME : J & J Leonards Well Drilling
PROPERTY LOCATION:
Okeechobee FL 34974
Lot:
Property ID: _
-1 - Well Construction
EXPLANATION or DESCRIPTION:
Block:
RECEIVED BY: VanceMH
Note: 59--31041 59-31040
QUANTITY FEE
2 $ 230.00
AUDIT CONTROL NO. 56PID 4655358