HomeMy WebLinkAboutWELL CONSTRUCTION PERMIT2.01 a. o�
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
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REPAIR, MODIFY, OR ABANDON AWELL
Permit No. 59-32264
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❑ Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS
Florida Unique ID
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O NorthWOSt ('Denotes Required Fields Where Applicable)
Permit Stipulations Required (See Attached)
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St. Johns River
Florida illnvmenrrfrrlmuncrnrhrnpalDbrrrartornpkfin�
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'+4 rpd
South rOrt/ammv!lnnvnrdfn�t6rp,mlil rry+pOmrlen to rim
0Suwannee River uppropiJdre JelrgdrcJuurhurrrytaFcreupullcubrv.
62-5240uad No, Delineation No,
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CUP/WUP Application No,
❑ Delegated Authority (if Applicable)
Moms & Angela Crady 9507 5 Indian River Drive Ft Pierce, FI 34982
'Owner• Legal Name it Corporation 'Address 'City 'Stale 'ZIP Telephone Number
2- 9507 S Indian River Drive Ft Pierce FI 34982
'Well Location - Address, Road Name or Number. City
3. 3519-444-0001-010-6
'Parcel ID No. (PIN) or Alternate Key (Circle One) Lot Block Unit
4.19 36S 41 E St Lucie Check if 62-524:❑ Yes ✓❑ No
'Section or Land Grant 'Township *Range 'County Subdivision
5. James P. Tyson 11352 954-818-4269 clovintliehofe@_att.net
'Water Well Contractor 'License Number 'Telephone Number E-mail Address
s. PO BOX 881495 Port St. Lucie FI 34988
'WaterWell Contrr�actor's Address City % nl ► p) { State ZIP
7. 'Type of Worw ,tJPI Construction ❑ Repair ❑ Modirication fWAbandonment (2) Wells t. 0) V 1I1I
8. 'Number of Proposed Wells 'Reaslm for Repair. Maaifralion or Abwdanmml
9. • pocify Intended Use(s) of Wetl s): Q
Domestic B Landscape Irrigation El Agricultural Irrigation ❑ Site Investigations
Bottled Water Supply Recreation Area Irrigation ❑ Livestock ❑ Monitoring
❑ Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation ❑ Test
❑ Public Water Supply (Community or Nan-Community/DEP)❑ Commerdal/Industrial ❑ Earth -Coupled Geothermal JUL 1 9 P02 1
❑ Class I Injection ❑ Golf Course Irrigation e HVAC Supply
HVAC Return �,G —
Class V Injection: ❑ Recharge ❑ Commercial/Industrial Disposal ❑ Aquifer Storage and Recovery ❑ Drainage DOH In St Lucie Co
Remediation: ❑ Recovery❑ Air Sparge ❑ Other luescaba)
❑ Other (0awibo)
10.10islance from Septic System If 5200 1. 11. Facility Description rOPO esen0e 12. Estimated Start Date
13: Estimated Well Depth 120 ft. 'Estimated Casing Depth 100 ft. Primary Casing Diameter 4 in. Open Hole: From _To ft.
14. Estimated Screen Interval: From 100 To 120 It.
15: Primary Casing Material: Black Steel Galvanized AgE>7C Stainless Steel
Not Cased Other.
16. Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel er
f a.'Method of Construction. Repair, or Abandonment: Auger Cable Tool Jetted Sonic
Combination (Two or More Methods) Hand Driven (Welt Point, Sand Point) Hydraulic Point (Direct Push)
Horizontal Drilling Plugged by Approved Method Other (Dasrribal
19, Proposed Grouting Interval for the Primary. Secondary, and Addluo Ing:
From_-!-- To 05 Seal Material ( Bentonite ^ ea nt Other )
From To Seal Material ( Bentonite eat Cement 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 2 List number or existing unused welts on site
21; Is this well or any exislinq well or water withdR.de
Fir the ownef s contiguous propertyy covered under a Consumptive/Water Use Permit (CUP/WUP)
or CUPNVUP Application'? Yestyes, complete the following: CIJP/WUP No. District Well ID No.
22. Latitude Lori-, f
23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
1haMrenarrMet -4OYoylrudhtllrnrptwUlafldea al Tdla 44 FfaAdnhhYdsaWin Code,"'if"'nvmfef Ictl4fy dm1lnmlhanMcrdlha MYad4y,Wn1IM1u L✓YrmiecY pu ridrdraMuunlv,nndnollnmveuo al m,
Wup4rrNwaroWNrNuranpnrwl,uncidtd, I.. h—. -I G.L., xd a!w lu mttrarr "ef.'a re:oe=!=,Mla efapu 77J. rmido9lifutoa. tonulnu4rwGoynrr ap�rd0ani�Nea, calaerury t4al{om
tanANtddn. IWNllx earcb llotyllmmfuddlldoidmr4lads applulot)Is actamld AM M31I%ir9bla+n lhoaaem:w thu eNw.41+al au hdpmAm podded is accn+da,aW tl+al l Im.11ifamed{ho enact of limb
nuYa:ary nppwilfmM aherfuderat Ywt Yl vocal aoiwMNu,::.n apP+ei4a. 1o0rtnlnpgYlde ay.ea relYYr0 Nd _aeetalcd nber Wnu<auentsto,awtna Pwe^'gelenK:lneloa.oelelattdAr,{henq aKw-.
wndNlMleamlblfm6iYW nialn_a dire der cmnplsYmnulltw rentrvcc..tauatr.InodACL�atw toxlYaeO dduriMWveYlrvuetia.r,]j(r`��nnd IraWn,orai+aMtu.mdnl alrllddxtd lrynnrrnrrit
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11352 67- 67 - 2y2 1
•Slnnawre of contractor
•Liaenue No. 'SI atureor0rrneror Agent 'bate
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Approval Granted 8 • C `� Issue Date ' Expiration Date Hydrologist Apptaval
--+oy�- mL•its
Fee Received S Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE VVMD OR DELEGATED AUTHORITY. THE
PERMIT 914ALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION. REPAIR. MODIFICATION, OR ABANDONMENT ACTIVITIES.
DEP Farm: 62-532.900(l) Incorpomted in G2-532.400(1), FA.C. EH..tim Data: October 7, 20t0
Mission:
��� t
y <�' ?
Ron DeSands
Governor
.TopmbacCpramae&inprovethe health
oral people in Floridathrough integrated
Deott A. wD
state, aunty&comnmdyefroft
LTH
HEALTH
State Surgeon General
Vision: To be fhe l iealthiest State in the Ndon
May 04, 2021
Vincent Valicenti, Associated Builders &
Developers, Inc
1817 SE Deming Avenue
Port Saint Lurie. FL 34952 '
RE: Modification to a Single Family Residence - No Bedroom Addition
Application Document Number: AP1658244
Centrax Permit Number: 56-SF-2275146
9507 S Indian River Drive
Fort Pierce, FL 34982
Dear Applicant,
This will acknowledge receipt of a floor plan and site plan on 04/23/2021 for the use of the existing
onsite sewage treatment and disposal system located on the above referenced -property.
This office has reviewed and verified the floor plan and site plan you submitted, for the proposed
remodeling addition or modification to your single-family home. Based on the information you provided,
the Health Department concludes:
1. the proposed remodeling addition or modification is not adding a bedroom; and
2. it does not appear to cover any part of the existing system or encroach on the required setback
or unobstructed area.
3. No existing system inspection or evaluation and assessment, or modification, replacement, or
upgrade authorization is required.
Because an inspection -or evaluation of the existing septic system'was not conducted, the Department
cannot attest to the existing system's current condition, size, or adequacy to serve the proposed use.
You may request a voluntary. inspection and assessment of your system from a licensed septic tank
contractor or plumber, or a person certified. under section 381.0101, Florida Statutes.
If you have any questions, please call our office at (772) 873-4931.
Sincerely,
Brian Ingram
Environmental Specialist III .
Department of Health in St. Lucie County
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Florida.Dapariment of Health www Horldrahr dth•Yov
in St Lucie County • 5150 NW Milner Drive • Port Saint Lucie, Florida TWITTER:HealthyFLA
34983 FACEBOOKFLDepartmentofHealth
PHONE: (772) 873-4931 YOUTUBE: fldoh
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St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
PAYING ON: #: 56-SF-2275146 SILL Doc #:56-BID-5264693 CONSTRUCTION APPLICATION #: AP1658244
RECEIVED- FROM: Associated Builders & Developers, Inc AMOUNT PAID: $ 245.00
PAYMENT FORM: CHECK 2064 PAYMENT DATE: .04/23/2021
MAIL TO: Morris Crady (Associated Builders & Development)
FACILITY NAME:
PROPERTY LOCATION:
9507 S Indian River Dr
Fort Pierce, FL 34982
Lot: Block:
Property ID: 3519-444-0001-010-6
EXPLANATION or DESCRIPTION:
QUANTITY
FEE
-1 - Surcharge (All)
1
$
45.00
123 - OSTDS Construction Site Evaluation
1
$
115.00
131 - OSTDS Construction Application & Existing System E
1
$
50.00
139 - OSTDS Application Approval Existing,'No Insp
1
$
35:00
I
RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-4953257
4
STATE OF FLORIDA
' DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
" [ ] New System
[ ] Repair
[ ] Existing System
[ ] Abandonment
PERMIT NO.5,r
DATE PAID: ZOZ�
FEEPAID: ,�•
RECEIPT #.: C K- o'Zab
[ ] Holding Tank [ ] Innovative
[ ] Temporary [• ]
APPLICANT: Cj f +i` a �►Y1 �i •mil G. Z- d' Cl y
AGENT: At,fA VPiootyTELEPHONE: 7-12-1~70-Q5-4�G
MAILING ADDRESS: 1-8 VT 5 L \J :e "'N ► A l� A i/ c •'"-t SA
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: BLOCK: _ SUBDIVISION: PLATTED:
PROPERTY ID #: 3,51 S -- 44 4 - .0 i 010 "'(,ZONING: I/M OR EQUIVALENT: [ Y
PROPERTY SIZE:IACRES WATER SUPPLY: [>4 PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y /0] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: 111
DIRECTIONS TO PROPERTY: U 0 ( c �' ^-�� c� �� Zt E c'..1V woa r O f"
BUILDING INFORMATION [ ] RESIDENTIAL [ ] COMMERCIAL
Unit Type of
No Establishment
1
2
3
A 4
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
Z 3��
,[ ] Floor/Equ' pment Drains [ ] Other (Specify)
SIGNATURE: V DATE:
DR 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4
r+F
STATE OF FLORIDA
s
^ ' DEPARTMENT OF HEALTH
_cry ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT n:
[ J New System [✓] Existing'System [ J Holding Tank [ J Innovative
Repair
[ ] Abandonment [ ] Temporary
APPLICANT:
AGENT: - / -c c. t! r ly ' cJ c,0 %) ` �i-y 7 C•Gr/i L T ELE PHONE :
MAILING ADDRESS: `� �� v -�v r ✓� i�Z l2 L /'iL f J c �-� t C� J, ?c,/ y �� ,
TO BE COMPLETED BY APPLICANT OR PPPLIC.ANT,S•AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED' PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTALTION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: BLOCK: SUBDIVISION: .i- 26> Xf -
C PLATTED: /
PROPERTY ID #: dl0ZONING. -ft I/M OR EQUIVALENT: [ Y0 ]
PROPERTY SIZE: ACRES WATER SUPPLY: [ ✓f PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ y ] \ DISTANC/E TO SEWER: FT
PROPERTY ADDRESS: _ 9SO 7 y, "W r` - L (�•
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [ RESIDENTI_L
[ J COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Soft Table 1, Chanter 64E-6, FAC
1 's aJ
2
3
4
[ J Floor/Equipment Drains [ ]
T. SIGNATURE:
Other (Specify)
DATE: 'Zy�
DH 4015, 08/ (Obsoletes previous editions which may not be used) I
V Incorporate 4E-6.001, FAC
c
Page 1 of 4
Y Off•,
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APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
Arras CrA-J
PERMIT w"
s OC.N,I -t t Uv 9(d i.,.1 �- iJ 2.✓Gl�Psr7
CONTRACTOR / AG\NT :
LOT: BLOCK: SUBDIV: .�>2� ''�- ID#: 3�l ! -�� • -c9a"�l c �
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON. SIGN A.ND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TIMI S CANNOT BE CERTIFIED.
EXISTING TANK INFORMATION •S s•S ail :�.
[ glitz J GALLONS SEPTIC TANK/G--D---M* LEGEND: �% -MATERIAL: L491 V BAFFLED: [Y /
[ ] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL: BAFFLED:[Y / N]
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL:
C J GALLONS DOSING TANK LEGEND: MATERIAL: 0 PUMPS:[ J
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON / /oi t7 BY %�'�� L , HAVE
THE VO MdES SPECIFIED AS DETERMINED EX FILLING / LEGEND ], ARE FREE OF OBSERVABLE
DEF OR gSANID HAVE A [ D FLECTION D / OUTLET FILTER DEVICE ] IN LED.
Ld-
S NATURE'OF LICENSED C NTRACTOR BUSINESS NAME DATE
XISTING DRAINFIELD INFORMATION
[ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [ ] STANDARD .[ ) FILLED [ ] MOUND j ]
CONFIGURATION: [ ] TRENCH [ ] BED [ ]
DESIGN: [ ] RUDER [ ] D-BOX [ ] GRAVITY SYSTEM [ ] DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
SYSTEM--T..NSTALLATION DATE TYPE OF WASTE [ / ] DOMEST [ ] COMNLRCIAL
GPD ESTIMATED SEWAGE FLOW BASED ON [ ] 'METERED WATER 1.4 TABLE 1, 64E-6, FAC
SITE 'I I DRAINAGE STRUCTURES [ ] POOL [ ] PATIO / DECK [ ] PARKING
CONDITIONS: [ ] SLOPING PROPERTY [ ]
NATURE OF [ ] HYDRAULIC. OVERLOAD [ ] SOILS [ ] MAINTENANCE [ ] SYSTEM DAMAGE
FAILURE: ( I DRAINAGE / RUN OFF [ ] ROOTS. [ ] WATER TABLE [ ]
FAILURE [ ] SEWAGE ON GROUND
[ ] TANK [
] D BOX/HEADER [ ] DRAINFIELD
SYMPTOM: [ ] PLUMBING BACKUP
[ ]
REMARKS/ADDITIONALL CRITERIA (5,�r;r % 71(
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SUBMITTED BY. -
DR 4015, 08/09
Y,�lcorporated ,6
4 `— .+- ,c 0 i��"J TITLE/LICENSE --re 00
,Obsolet s previous editions which may not be used)
-6.001, PAC
DATE:
Al
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