HomeMy WebLinkAboutHealth Department Septic Permit STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, J
REPAIR,MODIFY,OR ABANDON A WELL Permit No.
0Southwest Florida Unique ID 6 P/
PLEASE FILL OUT ALL APPLICABLE FIELDS
❑Northwest (*Denotes Required Fields Where Applicable) Permit Stipulations Required(See Attached)
OSt.Johns River The water well contractor is responsible for completing
2South Florida this form and forwarding the Permit upplicatiotltotile 62-524 Quad No. Delineation No.
❑Suwannee River appropriate delegated authority where applicable.
❑DEP I CUP/WUP Application No.
0 Delegated Authority(If Applicable) ABOVE THIS LINE-FOR OFFICIAL USE ONLY
f,Jake&Kayla Crouch 1012 SW Deuville Avenue, PSL, FL 34953 77 &1 3 A
*Owner;Legal Name if Corporation *Address *City *State *ZIP Telephone Number
2.8280 Germany Canal Road Fort Pierce FL
*Well Location-Address,Road Name or Number, City
3.3229-323-0004-000-2
*Parcel ID No.(PIN)or Alternate Key(Circle One) Lot Block Unit
4.29 36S 38E St Lucie Check if 62-524:❑ Yes❑ No
*Section or Land Grant *Township *Range *County Subdivision
5.Scott's Drilling, Inc. 11213 772-489-6117 scottsdrilling@bellsouth.net
*Water Well Contractor *License Number *Telephone Number E-mail Address
6.5014 Palm Drive Fort Pierce FL 34982
*Water Well Contractor's Address City State ZIP
7.%*Type of Work: 0 Construction ❑ Repair ❑ Modification❑ Abandonment
8. *Number of Proposed Wells ONE Raason for Repair. Riodification.or Abandonment
'9. *Specify Intended Use(s)of Well(s): A D PMVW E
[�✓ Domestic Landscape Irrigation Agricultural Irrigation Site Investigations Lr=61 l.r LRI V 1�
Bottled Water Supply ® Recreation Area irrigation g Livestock Monitoring
❑ Public Water Supply(Limited Use/DOH) ❑ Nursery Irrigation Test
❑ Public Water Supply(Community or Non-Community/DEP)� Commercial/Industrial Earth-Coupled Geothermal MAR 2 2 2017
❑ Class 1 Injection Golf Course Irrigation HVAC Supply
HVAC Return
Class V Injection:❑ Recharge ❑ Commercial/Industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage DOH in St Lude Cou
Remediation:❑ Recovery❑ Air Sparge ❑ Other (Describe) VIROMM H
)Other (Describe)
10. 'stance from Septic System if <200 ft. 11.Facility Description Inge aml y esl ence 12.Estimated Start Date
.*Estimated Well Depth 120 ft. "Estimated Casing Depth 100 ft. Primary Casing Diameter 2 in. Open Hole: From To ft.
14. Estimated Screen Interval:From 100 To 120 ft.
15"Primary Casing Material: Black Steel Galvanized ✓ PVC Stainless Steel
Not Cased Other:
16.Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17.Secondary Casing MSterial: Black Steel Galvanized PVC Stainless Steel Other
18."Method of Construction,Repair,or Abandonment: Auger Cable Tool Jetted ,/ Rotary T Sonic
Combination(Two or More Methods) Hand Driven(Well Point,Sand Point) Hy r Dint(Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Describe)
19.Proposed Grouting Interval for the Primary, Secondary, and Addi' a1-C-asiag�
From - 0 To 100 Seal Material( Bentonite - Neat Cement ` Other )
From To Seal Material( Bentonite ent Other )
From To Seal Material( Bentonite Neat Cement Other )
From To Seal Material( Bentonite 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 with n the owner's contiguous property covered under a Consumptive/Water Use Permit(CUP/WUP)
or CUPM/UP Application'? Yes ✓ No yes,complete the following:CUP/WUP No. District Weil ID No.
23.Latitude Longr ude
23.Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
!,hereby certify that I will comply whit the applicable miss of Title 40,Florida Administrative Code,and that a water I certify that IBM the owner of the property,that the information provided Is accurate,and that 1 am aware of my
use permit or artificial recharge permit.if needed.has been or wall be obtained prior to commencement of well responsibilities under Chapter 373.Florida Stalutes,to maintain or property abandon this well;or,I certify that I am
construction.I further certify that all information provided In this applicaltun is accurate and that I wall obtain the agent for the owner,th t the Informs vdvided is uccumte,and that I have infdrmed the owner of their
necessary approval from other federal,state.or local governments.if applicable.I agree to provide a well responsibilities as stale bove.O+ Bents to allowing personnel of this WMD or Delegated Authority access
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report to the Disldct wilhlp 30 days after complellon of the construction.repair,modification.or to the well sire door co tf pair,modification.or abandonment authorized by this permit.
abandonment aulhodzed b this permit.or the permit expiration.v.-hiche-mr occurs first.
11213
'Signature of Contractor 'License No. "Sigriofure of Owner or Agent 'Date
BELO71TH15 LINE-FOR OFFICIAL ONLY
q
Approval Granted By Issue Date 2 2 Expiration Date If 22 Hydrologist Approval
If Initials
Fee Received $ Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE MD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION,REPAIR,MODIFICATION,OR ABANDONMENT ACTIVITIES.
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B.Coatraet HS: See attached Cwlbacd cidc s pages for specific optim a]equipment LEN TOTAL CREDITS e)C7.
SALES TAX(If not included above)
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Titled Color: LESS LENDER PREPAID FINANCE CHARGES
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TRADE-F BB PAIDBY. ❑SAYER ❑SE IER F.AddWo dl ormddo
A Remarks and Nodees:
If this contiect requires the ordering of services which include.but are not limited to,an appraisal
title search, tit,per,sine inspations,and so fast,Uwe agree to pay for such
Eby wltbfield from my/our deposit Uwe understand that once such services
ayment for them sue nongddndMe.
Initial
includes normal delivery within 50 miles.House cat,extra miles blocking not included and
will be determined at site inspection.
At the d(scnedon of Palm Harhor Homes this t eb be stall and void or sabiect
ce ease no ow n taus o e ate o aereement
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FOM SSE WARRMW.ZXCLUSIONS ANDIMWATIONS OF DAMAGrB ON PAGE FOUR
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074 document-edited-.xdml Last Revised On:5/13201511:48:08 AM For FL 5%New Chattel Package