HomeMy WebLinkAboutWater Well PermitsMission:
To protect, promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
HEALTH
Vision: To be the Healthiest State in the Nation
Ron DeSantis
Governor
Scott A. Rivkees, 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.
a. Call the FDOH — St. Lucie Well Line at 772-873-4936 or email
SLCDOH-WELLSCED,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-WELLS(aD-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 St Lucie, FL 34983 Public Health Accreditation Board
PHONE: 7721462-3800 - FAX: 772/871-5360
StLucieCountyHealth.com
STATE OF FLORIDA PERIVItTAPPL(CATION TO CONSTRUCT,
REPAIR, MODIFY, OR A6NDON A WELL
❑ Southwest PLEAST A E FILL OULL APPLICABLE FIELDS
Northwest ("Denotes Required Fields where Applicable)
C.1St.
outh Florlda nruRater wellcuniroctortsresponsiplefureMnplenng
rhfs form and famading 1llepeanirapplicarian to the
O DEP
fiver appraprtrrtif*12- arWMUMMY Wilureappilrable.
CJ Delegated Authority (If Applicable)
• uatluii l - MUurvus, KOK INaml
3.4--�Qt —r7r
`Parcel ID No, (PIN) or Alternate Key
4.4
� cfon or Land Grant Towns ip
5. P NV.ir;i•r': t"i`1f. 11't:
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No. 59-30485
Unique ID V_
Stipulntfons Required (Sao Attached)
62-524 Qugcl No. Delineation No.'
C3P/WUP Application No,
Telephone Number
Block Unit
if 62-5240 Yes No
' + �+ J Ucense Nurclber-ti)6""Teiep�hope Number E-m it Address
Water
Well Contra tor's Address City State ZIp
7. 'Type of Work: Construction ❑ Repair ❑ Modification❑ Abandonment
8. 'Number of Proposed Wells_ aasorrfor Rap:dr, MadlrirMAY'
9�*"Specify Intended Use(s) of Well(;):
Domestic Landscape Irrigation Agricultural Irrigation Site 19 Jvestigations
Bottled Water Supply ® Recreation Area Irrigation ® Livestock ® Montt ring
❑ Public Water Supply (Limited Use/DOH) �] Nursery Irrigation Test 1 r
Public Water Supply (Community or Non-Community/DEP)❑ Commercial/Industrla! Earth Coupled Geotherm5 20r
�] Class I Injection ❑ Goff Course Irrigation HVACISupply
HVAC Return
Class V Injection: ❑ Recharge [] CommercialAndustrial Disposal [] Aquifer Storage and Recovery [] Drainage DOH in St Lucie Cc
Remedlatiorr [] Recovery [] Air Sparge ❑ Other (Mccribe) E VIRy jjyj( jj�,pL HE❑ Other (Daacnbol i
10,'Dl�tanrf, frorl5 Saottc ,^yeft:m if S 9p0 ft _ 1i Farility DFInf•riptinn iD Pstirnatpo gfaH l�afA
13.'Estimated Well Depth it.-Estimat Casing Depth v fL PrimaryCasing Diameter ln. Open Hole: From To ft.
14. Estimated Screen Interval: From Td Z�Q ft.
15'Primary Casing Material: Black Steel ' Galvanized Stainless Stlbel
Not Cased Other:PVC _ - i
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter Iin,
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel 1Other
18.1Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted ; Rotary Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) F�ydraL111D ant (Qirect Push)
Horizontal Drilling Plugged by Approved Method Other (owl; Point)
of i
19, Proposed uting In v for the Primary, Secondary, and A a I
From To Seal Material { d3entonite Neat Ceme Other )
From To Seal Material ( Bentonite Ne� Other )
From To Seal Material ( Bentonite Neat Cement Other
From To Seal Material ( Bentonite Neat Cement Other )
20. Indicate total number of exlsttng wells on site List number of existing unused Hjells on site
21.1s this well or any existin� well or water with wal of the owner's contiguous proper covered under a ConsumptiveNWater Use Permit (CUPNVUP)
or CUPNVUP Application. Yes No I es, complete the following: CUPNVUP No. ; District Well ID No.
22, Latitude Longitude Ii
23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS t34
I hafrsby cdmly Nall vAl comply 1M01 Na apylroabtu Wee of rdla /0, Is�iauuaundvu coo*. tlM1 dldl a'Nldflr I Wrify nlal I afrl rho owner al d1U prriyafly, NYI drY ell°IalYbell pfaVldid Ia dCWfal4, Wid Nut 1 urn aware of my
wa yurndt arndkYfl rochurpu pormlq d needed. tare bean or Will ua obudnad poor to aotIlk cameal of wall fauparnWilboo undur Chaplar 073. Florlda stptowc, to InYyihlYf ur prapaly ubanRC, Nu welb of.I oerilfy aml I um
camaueaoe. Iluratar corUA'that GOinfanaadm, providod in lhlo applkudan lu acwrata and Nat 1-4 ot+toin Nv uatml ter Ne armor. lhul No orfafipabon Id it to aceorute. and lllnt l haw lnformad IN owner of tlrofr
aaepseafy fppovdlbram other ladaral, elate, ortoeot govmnm llogj •appile, , 1 anroa lop# it o yM (WOnelblikoa ll slalud ua , owner cp . d Iwving paRennalaf this WMD or0olepaledAulhonly amuts
0faindi ni tepottld Ifro bV this
P011a"�gddya ■her apmpi all n o(dta leyv Uctbn. repel, mpte4aaoon, or to the wdtAl14 Mohte the liefu.. Ir AGO .or ubomplunefil dulherim by this peffi t.
ahandonmarl audwfirad by Ih& permit, ar the aormit e>Ipiradon, rWr?Mawr orau% amr.
ao
'8i Vnaturq of Contractor Llcanse or O No. SI nature "
- 0 ` en 'Data
Approval Granted By Issue Dale Expiration Date 9jp HydratogiatApproval
Fea Received $ Inlets
Receipt No. Cbe No.,
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVEPF THE WMD OR DELEGATED AUTHORITY. THE '
• PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION. REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES.
DEP Farm: 62.532.900(1) Incorporated in 62 532.400(1), F.A.C. Effective Dais: October 7, 2010 Page 1 of 2