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
Rick Scott
Governor
Celeste Philip, MD, MPH
State Surgeon General and Secretary
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-WELLS a(,FLHEALTH.GOV
b. Provide the following information:
L 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(cD-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 • Division of Disease Control and Health Protection
Bureau of Environmental Health
5150 NW Milner Drive
Port St Lucie, FL 34983
PHONE: 772/873-4931 • FAX: 772/595-1306
FloridaHealth.gov
Accredited Health Department
• Public Health Accreditation Board
Y
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
-
o q 17$
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: .M�akvs!et�.y
REPAIR, MODIFY, OR -ABANDON A WELL
❑SOuthwast PLEASE FILL OUTALLAPPLICABLE FIELDS
❑Northwest (*Denotes Required Raids Where Applicable)
❑qt-Johns River
Outh Florida fiewvferwetl eonfinefarls raspenstele /orcamplef ng
this fam and forwarding the pemdl epplicaeon to the
❑Suwannee River appmowedelegereda.momywnereeppeivaare.
ODEP '
❑ Delegated Authority (If Applicable)
1, ('4grr IVIr— zuuflu
2. '0Wggi�yeme [);Drporatiot
'Well Ld tljjo��� d Road�No
3. _ Z-2TS� r0 -ox
'Parcel 1Jg IN) crAlle I&E
4. /
'Section or t.and Grr• nt To
'W/ r Wall I ctor
7-14
No.
Unique ID
SepuloWns Required (See Attached)
Quad No. Delineallon No.
'UPAppliceeon No.
it �P >Cj NyT.SE�
Stock Unit
Check If 62- _ Yea _ No
7. *Type of Workn Constructlop _Repair —Modification Abandonment . J7 /7
%8. Wells ^ Re. o tarRapar. Medl V nm
g. •S fy
ZIntended Use(s) of Wall(s): Dale'5lamp
Domestic —Landscape Irrigation ___Agriculture t Irrigation _Site Investigation
—BbtUad•WaterSupply _RecieationArea Irrigation —Livestock —Monitoring
_Public Water Supply (Limited Use/DOH) —Nursery Irrigation Test
Public Water Supply (Community or Non-Community/DEP)—Commemiellindustdal _Ebrth-Coupled Geothermal DEC
_
—Golf Course Irrigation _HVAC Supply
—Class I Injection —HVAC Return
Class V Injection:—Reoharge _CammrrcleUlndustrial Disposal —Aquifer Storage and Recovery —Dralnage F H M St LUde C
Remadia0on:—Renovery Air Sparge —Other IDaWtuil
other eeoalbe ENV ONMEMAL H
�_ ( i (Nola:Naafl"asalwah mpermnlodbye,Ivan pennllting euNylH)
10'Distance from Septio System If s200 tt. 11. Facility Description go 12. Estimated Start Date
3 `
1Estimated Well Depth fL 'Estimated Casing Depth , -Primary Casln Diameter in. Operi Hole: From_To It.14. Estimated Screen in Fromint-_To,50 1t,
16.•Pdmary Casing Material: _Black Steal _Galvanized _PVC _Stainless Steel
_Not Cased _Other.
16. Secondary Casing: _Telescope Casing _ Liner _ Surface Casing Diameter in.
17. Secondary Casing Materiel: _Black Steel _Galvanized _PVC _Stainless Steel t oar
18-Vothod of Construction, Repelr, orAbandolArtent: Auger _Cable Tool melted _fG/fiotery Sonic
_Combination (Two or More Methods) _Hand Driven (Wail Point, Sand Paint) _Hydraulic Point (Direct Push)
_Hodzontal Ddliing _Plugged by Approved Method Other (oeaoibei
tg. Proposed Grouting 1 to 1101 the Primary, Secondary, end Add : net Casing:
From �l[1' _To�Seal Material �_Bentonite_ eat Cement Other /
From • To Seal Material (_Bentonite_Neat Cement Other
From. _ To seal -material L_Sentonite_Neat Cement Othor
From Ts. ' Sea( Materiel L_Bentonite Neat Cement Other )
20. Indicate total'numberofox(stingwellsonsite List number ofexistingunused wells ansite.
�
21 'Is this well crony existing well orwaterwithdrawal on the owner's contiguous property covered under s ConsumptIvalWater Use Permit (CUPMLIP)
or CUPf WUP Application? _Yes _No If yes, complete the following: CUPIWUP No. Distdpt Wel1ID No.
22. Latitude Longitude
23t Data Obte'inod From: GPS _Map _survey Datum: NAD 27 NAD 83 WGS 84
Iliwtprta�4a l.rlWephrrlN M.ppOreW ruuanli �o; FlDlaaMmWtinlrya CoO.. mldulalnW henry bdlmb. wmnaeupnpaM.matrn Nhlmapn pmNEtl"u Kml uuil mM I
taspmYlnaMeW nmaR.pmlkelma.a.tmtmov.meaawnwpnorgmm.ancmunttlwp nepondutmnw1:=1tadri, Raba amwa61amtblmea pleptat a"dM lNawebv.4 tt.ry=1
tplsinpen llufaan,aye,a.nodmurm y.MteNaJ..paur_,o¢amb ua Wllr7 as.r, Na arorMumr, NltaplMamulba eramWr�.ca.alR meeal.m ldoim.e pLa.'NfaeW
oaf+aD�arramaPvtawLaW.vem.agmeri�pad�b. t.amampmdfu.rnu �auuu Wlae.ewa omvmmm.orbNnY P.mmnYatliY WebmnW9.W 11maNYuao
�OeOoa npodbaneebtdiAMn�00ap abtmlryplaeabatondadm,taett moaltatbo,a � •' aYi du4ysiomNWCEmi,npe$moOWfm,aaaalmmeaaAaeadgMpmm.
rnwaamntammEaoqutl.pmt�trmvuma.�.un.l.a...rata,nnn. /
/, A,7e l
Approval Granted By
Fee Received S
Form 62S32.6ml)
Issue
JNG AWCONSTRUCTION, REPAIR. 6
FAC. E6eclive Date: Octotier7, 2010
Expiration Date W/5MI'7 Hydrologist Approval
Check No.
rrATrvE OF THE WMD OR DELEGATED AUTHORITY. THE
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