HomeMy WebLinkAboutWater Well PermitsVI?
Ron DeSantis
Mission: Govemor
To protect, ptomote & improve the health
of all. people lnflorldR�through-Integrated
Scott A, Rivkees, MD
stale; county & communityefforf-
H FA CT H. State SuMeon General
Vision: To be he HealthlestStatein the Nation
Florida Depart.mont, of Health in St. Lucie County
ConditionsforIssuance of Water Well Permits
Effective July .24,.2017
0 Contact the Florida Department of Health in Saint. Lucie County (FDO.H — St. Lucie),
prior to constructing or abandoning any well.,
4Cal. — f the. FD(�H: — St. Lucie, Well Line at 772-8784936 or email.
�
,SLOOOHMELLSArl-HEALTH. GOV
b. Provide the following. information:
I. Permit number
Ii. Dri.110-r name:
ilia Address
iv. DaAe,and time to begin. construction../abandonment
Aminimum of.24 hours' notice is required before constructing any public water supply
wells. Please,zall Wrmdin: office. at 772.873-4931 and' speak with Environmental
Health Staff or provide notification by email to SLC-DOH�WELLSe-'FLH.EALTH.:GOV
• gubmittev* 6 Within 48 hours of-. well
IsJons to per.mit-and/or datto e, , fee site ciat d- f
c6ristrfi on, or 4icp'bbAdohment.
i,
:Florida; Departmentrof Health
Accredited Hoolth'Department
5150 WNW DrNe -Pod SL Ldiddf FL 34983 ic ealth Accreditation Boa
NHWIE: V21462-3.800 - FE� -1721871436.0• Pubr. .H
6tLucIdCountykbhIth.'doIn
STATE` OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
❑Southwest
❑ Northwest
PLEASE FILL.OUTALLAPPLICABLEFIELDS.
(*Denotes Required Fields (Were Applicable)
El St. Johns River
aScuth Florida
❑Suwannee River
The water well contractor Is responsible forcompleting
this form and forwardingthe.permit application to the
appropriate delegated authority where applicable.
eI gated Authority. (If Applicable)
4. 09 " Site, ST L(. ael-
`Section or Land Grant *T hip *Range *County
/cam 3ar
'*Water erW II Cont.a� `License Number *TeI
6.
Permit No. 59-31085
Florida Unique ID
Permit Stipulations Required. (See Attached)
162-U4 Quad No.. Delineation No.
GUPIWUPApplieation No.
'ZIP *Telephone Number
Lot Block Unit
CDbck if'62-524:_ Yes y No
Z, *Type dUWorks,_ZCon6trustion _Repair _Modification
&:sNu(.nber of Proposed Wells,.
_Abandonment .
'ReasonforRepair, Modification, or Abandonment
�r StamR
D D' D
9. `S�p ity;intended' U1.se(s)of Well(s):
S/Domesiic Landscape Irrigation;
Agricultural Irrigation
_Site Investigation
_Bottled Water Supply _Recreation Area Irrigation _Livestock
_monitoring
Public WaterSupply (Limited USeIDOH) ^Nursery
Irrigation
Test
Coupled Geothermal
_PublioWaterSupply (Comrunity ov Non-Community/DEP).=Commercial/Industrial
_Golf
Course Irrigation
_Earth
HVAC Supply
OCT
_Class l Injection
_HVAC,Return
Class. V Injection;Recharge _Commercial/Industrial Disposal _Aquifer Storage and Recovery.Draina
Remediafion:=Reccveiy._AirSparge_Otlq.(gesorba)
FD;�1(;
Othef"(Describe). I (Note: Nol all types ells are perniltled by,a given permHtin9 authority)'
10.'Distance'from Septic Sys a if s2QU; ft. 11. Facile ription 12. Estimated Start DafenS
.
13."Estimated. Well Depth ft. ` timated ' asing Depth ft.. *PrimaryCasing Diameter in. Open Hole: Erom To ft.
14. Estimated Screen interval: Fro"12-0
Primary Casing (Material: Black Steel Galvanized PVC Stainlesg Steel
NotCased: �—Other:
1:6..SeconJary Casing: Telescope Casing V Liner Surrace Casing Diameter .in.
17'. Secondary Casing Material. Black Steel Galvanized VC, Stainless Steel Other
18;4'.Meth6d or Construction Repair, drAbandonment: Auger Cable Tool Jetted Rotary Sonic
(3gmbination (TWo or More Methods) Hand Dr(yen (Well Point, Sand Point)' Hydraulic Point(D)rectPush)
Horiionta4Driliing Pltjgged tyy.Approved Method Other (Desodbe)
19. Proposed Grouting Interval for the Primary;. Secondary, and Additional Casmg:
From To Seal 96ted6l,( Bentonite . Neat Cement Other I.
From ' to Seal Matertat ( Bentonite Neat Cement. Other }
From To Seal Material( Bentonite Neat Cement Other
From To Seal Material �Benf 'nite Neat Gemanf . Other 1
20..Indidate total numberof existing wells:onsite. Ltst ni mberofexist ng unused wells on site
21::*Is this well or anYexistmg W:elLorwaterwit rawal on the owner'scontrguous property covered under a Consumpt(velWater Use Permit.(CUP/W.UP)
or CUP/WUP Applicatlon? Yes V.No If yes, comptete;the following: CUP/WUP No: District Well ID No.
22. Latitude /Longitude .
A Data Obtaine.d Frotn: GPS -/ Map: Survey Datum: NAD 27 NAD 83WGS 84:
rlieretry cerli(Y'Oi'all:wll4eainPlYwllh.p,e:'eoolleebl6 Niea of.111(e4a;Flo'rtAa"ACminialraUY9 Code,and 0ietewaist feeN&4hat Iamthe awnerbr the proeerty.. that aieintnmiallon prodded' I! acWraW,.aM that l am;eweM,gVmy
Approval Granted
Fee Received S
THIS PERMIT
Receipt No.
�3
8/24
-•D,ats
Expiration Date
Check..No.
VE OF THE1iWMD OR DELEGATED AUTHORITY THE
DEP Form: 62-532000(1) Incciporated.in 62-53Z400(1), F.A.C. Effective Date: October 7, 2010 Page 1 of 2
------------ SUR
PARCEL. ID:
1309^411-0001=000-0
7
i. OF
IINE
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BUILDING DETAIL &
GRAPHICSCALE
1,3
c
Ut.
St. Lucie County
Health Department
is 5150 NW Milner Dr Port Saint Lucie, FL 34983
HEALTH
PAYING,ON' m56-SF-2165577 SILL DOC #:56-81D-4982989 CONSTRUCTION APPLICATION CATION M. AP1577433
RECEIVE[? FROM,: Adair Garcia AMOUNT PAID: S 660i00
PAYMENT FORM-' CHECK, 190 PAYMENT DATE: 09/1,0/2020
MAIL TO: Adair Garcia
FACILITY .NAME
PROPERTY LOCATION -.-
TOO - Johnston Rd
Fort Pierce, FL 349.5-1
Lot:- -840qk;
Property ll)r.i 1209-411-0001-QW-0
EXPLANATION or DESCRIPTION: - QUANTITY FEE
128 - OSTDS Construction $yqtem:Inspectfon Research Fee 1 $ 5woo
4 - Surcharge (All) 1 $- 45.00
A - 08TD8 New Permit Surcharge
-1 - OSTDS-Constructi
on . Application and Plan Revfew,New.
123 - OSTIJ.8 CidnstrUdri6h:
I .Ite Evqlultio.h
1.26 - OSTDS Construction. Permit (New or Mod, Amendment)
127 - OSTDS Construction -$.y$;te,m Inspection
1133 - 0 D.S. Construction . I ST. - action Roinspection
-1 - Well Construction
RECEIVED BY WhiqhaM.JL
$ 100.00
$ 100.00
1 $ 115.00
1 $ 55.00
1 $ 75.00
$ 50:.00
$ 11 U0
AUDIT CONTROL NO. 56-PID-4660137'