HomeMy WebLinkAboutHealth Dept Septic Approval PERMIT #:66-SF-2362418
STATE OF FLORIDA APPLICATION #:AP1715209
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
•'� SYSTEM RECEIVED
RECEIPT #:
0 C T 2 12020 DOCUMENT #:PR1673687
St.Lucie County
Permitting
CONSTRUCTION PERMIT FOR: OSTDS New
a
APPLICANT: Justin&Cheryl Allen f19 F}I tip^,
2080 Pulitzer Rd Fort Pierce, FL 34945
PROPERTY ADDRESS:
"' (:� 4i,L'4!1{.."-+P. \+a�,/T •LW fill",
LOT: BLOCK: SUBDIVISION: d vR T
PROPERTY ID #: 2317-333-0000-000-2 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND ' CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE ' IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE , OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,050 ] GALLONS / GPD Septic new CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 667 ] SQUARE FEET Drainfield new SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [x] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: Nall in E side Of N gate post
I ELEVATION OF PROPOSED SYSTEM SITE [ 21.001 [ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 7.00 it INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [32.001 INCHES EXCAVATION REQUIRED: [ 9.00 ] INCHES
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow of
O 400 gpd.
T
H
E
R
SPECIFICATIONS BY: Brian 'J I am TITLE' Environmental Specialist III
APPROVED BY: TITLE: Environmental Specialist III St.Lucie CHD
Brian J*Itickam
DATE ISSUED: 10/13/2021 V EXPIRATION DATE: 04/13/2023
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC*`�" Page 1 of 3
v 1.1.4 AP1715209 SE1610018
r
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department,within twenty-one(21)days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN A-02,Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order will
constitute a waiver of your right to an administrative hearing, and this order shall become a'final
order'.
Should this order become a final order, a party who is adversely affected by it is entitled
to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are
governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced
by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a
second copy, accompanied by the filing fees required by law,with the Court of Appeal in the
appropriate District Court. The notice must be filed within 30 days of rendition of the final order.
St. Lucie County Health Department
HEALTH
5150 NW Milner Dr Port Saint Lucie, FL 34983
PAYING ON: #:56-SF-2352418 BILL DOC#:56-BID-5542892 CONSTRUCTION APPLICATION#:AP1715209
RECEIVED FROM: Gem Builders, Inc AMOUNT PAID: $ 545.00
PAYMENT FORM: CHECK 14673 PAYMENT DATE: 08/18/2021
MAIL TO: Justin & Cheryl Allen
FACILITY NAME :
PROPERTY LOCATION:
2080 Pulitzer Rd
Fort Pierce,FL 34945
Lot: Block:
Property ID: 2317-333-0000-000-2
EXPLANATION or DESCRIPTION: QUANTITY FEE
128-OSTDS Construction System Inspection Research Fee 1 $ 5.00
-1 -Surcharge (All) 1 $ 45.00
-1 -OSTDS New Permit Surcharge 1 $ 100.00
-1 - OSTDS Construction Application and Plan Review,New 1 $ 100.00
123 -OSTDS Construction Site Evaluation 1 $ 115.00
126 -OSTDS Construction Permit 1kAnd Amendment) 1 $ 55.00
127 -OSTDS Construction System I vl ;A 1 $ 75.00
133 -OSTDS Construction Reinspe 964 1 $ 50.00
COOS
RECEIVED BY: AdamsC __ ROL NO. 56-PID-5166973
' y • c
STATE OF FLORIDA PERMIT NO•
DEPARTMENT OF BEALTH DATE PAID:
ONSITE SENAGE TREATMENT AND DI FEE PAID:
' SYSTEM RECEIPT #: Ul to 13--i:
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
New System [ ] Existing System [ ] Holding Tank [ ] Innovative
Repair [ ),,,Abandonment �1 t ] T,
APPLI
t
it TELEPHONE:
LING ADDRESS: n
TO BE COMPLETED BY APPLICANT OR APPLIC4ZIS AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
8Y A PERSON LICENSED PURSUANT TO 489.105(3) (:m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION O8 THE DATE THE LOT WAS CREATED OR
PLATTED (MH/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION �LV Y* ? V
LOT: BLACK: SUBDIVISION:kes5ff - � `� PLATTFsD
PROPERTY ID #: r. ; ;J.7' - Q ' KING: I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE:1 ACRES WATER SUPPLY: [ZRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GED
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y j DISTANCE TO SEWER: FT
PROPERTY ADDRESS:
DIRECTIONS TO $ROPERTY:
g
14C �1'As &L)kdC)y jel', //,o su" _,,7dql &2t-�7
04 %
BUILDING INFORMATZON REBIDw
1E i t C9 RC l�
ar
Unit Type of No. of Building Commercial/Institutions]./System Design l'
No Establishment Bedrooms Area S91t Table 1, Chapter 64E-6, FAC
4
2 AW4
3
4
�=A
Floor/Equi fraias [ ] Other (Specify). DATE: 9,
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, PAC Page 1 of 4
STATE OF FLORIDA APPLICATION # AP1715209
DEPARTMENT OF HEALTH PERMIT # 56-SF-2352418
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE1610018
SITE EVALUATION AND SYSTEM SPECIFICATION
APPLICANT: Justin&Cheryl Alien
CONTRACTOR / AGENT: Gem Builders, Inc
LOT: BLOCK:
SUBDIVISION: ID#: 2317-333-0000-000-2
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 19.68 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES-TABLET / OTHER-TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 29520.01 GALLONS PER DAY [ 1500 GPD/ACRE I OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 2000.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Nail In E side Of N gate post
ELEVATION OF PROPOSED SYSTEM SITE 21.00 [ INCHES / FT ] I ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 100 FT NON-POTABLE: FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 100 FT POTABLE WATER LINES: 46 FT
SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO]
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES: USDA SOIL SERIES:
Munsell#/Color Texture Depth Munsell#/Color Texture Depth
1 OYR 5/3 Fill-Sandy Clay 0 To 7 1 OYR 5/3 Fill-Sandy Clay 0 To 9
10YR 4/1 Loamy Sand 7 To 10 1 OYR 4/1 Loamy Sand 9 To 12
1OYR 512 Sand 10 To 20 1OYR 5/2 Sand 12 To 23
1 OYR 6/8 CMN/PRM RF 10 To 20 1 OYR 6/8 CMN/PRM RF 12 To 23
10YR 6/6 Sand 20 To 37 10YR 6/6 Sand 23 To 30
10YR 4/3 Sandy Clay Loam 37 To 42 1OYR 4/3 Sandy Clay Loam 30 To 44
5BG 6/1 Sandy Clay Loam 42 To 57 5BG 5/1 Sandy Clay 44 To 53
HOLE CAVING Refusal 57 To 72 HOLE CAVING Refusal 53 To 72
OBSERVED WATER TABLE: 24.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 10 INCHES [ ABOVE / BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X]YES [ ]NO DEPTH: 10.00 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Loamy Sand/0.60 DEPTH OF EXCAVATION: 9 INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [X] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA
WSWT determined using USDA WSS and soil borings.
10YR5/8 CMN PROM RF mottling In 10YR512 matrix>2%starting at 10"in SB1.
SB1 21"below BM. SB2 22"bel?f BM.
SITE EVALUATED BY: DATE: 10/12/2021
Ingram,Brian I e:Environmental Specialist III)(ENVIRONMENTAL HEALTH)
DH 4015, 08/09 (Obsoletes previous editions ch may not be used) Incorporated: 64E-6.001, FAC Page 3 of 4
AP1716209 EID2352418 v 1.0.2
STATE OF FLORIDA PERMIT #k.
DEPARTMENT OF HEALTH
1% ONSIT SET"wax TkZEAT=,XT Alm DISPOSAL SYSTEx
ch SITE EVALUATION AND SYST Pa`CT CATQNS
APPLICANT: / G k�3 lf.�1.d, o '-� `
LOT: BLOCK: SUBDras ON.—
�j}} cc � I
PROPERTY ID # :,� , LJ I Section/TownslaAp7S'a�e o.or Tax ID Number ]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIF= PERSON- ENGINEERS
ROUST PROVIDE REGISTRATION NUIMER AND SIGN AND •SEAT, EACH- PAGE OF SUBMITTAL. COMPLETE//ALL ITEMS.
PROPERTY SIZE CONFORMS TO S ITE P ( YE S I I NO NE T USABLE .AREA AVAILABLE
-TOTAL ESTIMATED SEWAGE FLOPf: . �(/� GALLONS PER DAY (RESIDENCES-TABLE I/O>,'HER-TABLE2 ]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY I 1500 QPDIACRE OR 2500 GFD A RE 1
UNOBSTRUCTED AREA AVAILABLE: D (0 SQFT UNOBSTRUCTED AREA REQUIRED: �J � SQFT
BENCHMARK/REFERENCE POINT LOCATIO '
►�Za l
ELEVATION OF PROPOSED SYSTEM SITE IS I INCHES/F r I (ABO /BELOW 7 BENCHMARK/REFJhP NCE POINT
TILE MIxncu SETBACK WHICH CAN BE MAINTAINED FROM THE,,P�ROPOSED SYSTEM. TO THE FOLLOWING Er" "S
SURFACE WATER: FT DITCHES/SWALES: �G' FT ,N/ORI�yBiLZY WET? [ l YI;B ��NO
WILLS: PUBLIC: FT L TED USE: �� FT TF�:- /, �FT NON—POTABLE: Ii T
BUILDING FOUNDATIONS: /� FT PROPERTY LINE �FT /. POTABLE WATER LINE:� T
ei '�
SITE SUBOECT TO FREQUENT FLOODING: I ] YES [4 NO 9.0 YEAR FLOODIAG? ( ] XTS. I ] NO
10 YEAR FLOOD BLEVATION FOR SITE: T MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
MUNSZLL #I/COLOR TEXTURE DEPTH MUNSELL #I/COLOR TEXTURE DEPTH
TO TO
TO TO.
TO TO
TO TO
TO TO
TO TO
TO TO
TO TO
TO TO
USDA, SOIL SERIES: USDA SOIL SERIES:
OBSERVED WATER TABLE- INCHES (.ABOVE/BELOW r] EXISTING GRADE. TYPE: [FERCHED/APPARENT 7
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [,ABOVE/BELOW a EXISTING GRADE
HIGH.WAIER TABLE VEGETATION: j ] ICES j ] NO MOTTLING: I ] YES ( ] NO DEPTH: INCHES
SOxL.TAXTURIa/LOADAW RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES
DRA;INF,IELD CONFIGURATION: [ ] TRENCH j ] BED I ] OTHER (SPECIFY)
REMARKS/ADDITIONAL, CR
cy
SITE E / DATE: �7
DS 4015, 12/11 (Obsoletes previous editions whiolt xnnot-li® s d) RCOfp0lated: 64E-6.001,FAC Page 3 of 4
Michelle Franklin, CFA-- Saint Lucie County Property Appraiser--All rights reserved.
Property Identification
Site Address:2080 Parcel ID:2317-333-0000- Account#: 13892 Sec/Town/Range: 17/35S/39E
PULITZER RD 000-2 Map ID:23/17S Zoning:AG-5 Count
Use Type:9900 Jurisdiction:Saint Lucie
County
Ownership Legal Description
Justin M Allen 17 35 39 S 1/2 OF SW 1/4 OF SW 1/4-LESS W 44 FT(19.68
Cheryl L Allen AC)
105 NW Swann Mill CIR
Port St Lucie,FL 34986
Current Values Historical Values 3-year
Just/Market: $282,000 Assessed: $282,000 Year Just/Market Assessed Exemptions Taxable
Exemptions: $0 Taxable: $282,000 2021 $282,000 $282,000 $0 $282,000
2020 $237,442 $5,412 $0 $5,412
2019 $237,442 $5,412 $0 $5,412
Sale History
Date Book/Page Sale Code Deed Grantor Price
04-08-2021 4591/0589 0001 SP CENTERSTATE BANK NA $315,000
03-05-2021 4566/1606 0118 CT Callaway Matthew A $275,100
03-28-2018 4114/1093 0001 WD PENSCO Trust Company $340,000
Primary Building Information
Finished Area of this building:0 SF
Gross Sketched Area:0 SF
Exterior Data
View: Roof Cover: Roof Structure: Building Type:
Year Built:N/A Frame: Grade: Effective Year:N/A
Primary Wall: Story Height: No.Units:0 Secondary Wall:
Interior Data
Bedrooms:0 A/C%:0% Electric: Primary Int Wall:
Full Baths:0 Heated%:N/A% Heat Type: Avg Hgt/Floor:0
Half Baths:0 Sprinkled%:0% Heat Fuel: Primary Floors:
Total Areas
Finished/Under Air 0
(SF):
Gross Sketched Area 0
:. ." (SF):
Land Size(acres): 19.68
Land Size(SF): 857,260.8
Total Building Count: 1
i
Special Features and Yard Items
Type Qty Units Year Blt
All information is believed to be correct at this time,but is subject to change and is provided without any warranty.
0 Copyright 2021 Saint Lucie County Property Appraiser.All rights reserved.
} Custom Soil Resource Report
St. Lucie County, Florida
32—Pineda sand, 0 to 2 percent slopes
Map Unit Setting
National map unit symbol. 2x1 nb
Elevation: 0 to 100 feet
Mean annual precipitation: 47 to 58 inches
Mean annual air temperature: 70 to 77 degrees F
Frost-free period: 355 to 365 days
Farmland classification: Farmland of unique importance
Map Unit Composition
Pineda and similar soils: 85 percent
Minor components: 15 percent
Estimates are based on observations, descriptions, and transects of the mapunit.
Description of Pineda
Setting
Landform: Drainageways on marine terraces, flats on marine terraces
Landform position(three-dimensional):Tread, dip,talf
Down-slope shape: Linear
Across-slope shape:Concave, linear
Parent material.Sandy and loamy marine deposits
Typical profile
A-0 to 5 inches: sand
E-5 to 19 inches: sand
Bw- 19 to 35 inches: sand
Btg/E-35 to 38 inches: sandy loam
Big-38 to 60 inches: sandy loam
Cg-60 to 80 inches: loamy sand
Properties and qualities
Slope:0 to 2 percent
Depth to restrictive feature: More than 80 inches
Drainage class:Poorly drained
Runoff class: Very high
Capacity of the most limiting layer to transmit water(Ksat): Moderately low to
moderately high (0.06 to 0.20 in/hr)
Depth to water table:About 3 to 18 inches
Frequency of flooding:None
Frequency of ponding: None
Calcium carbonate, maximum content:4 percent
Maximum salinity: Nonsaline to very slightly saline(0.0 to 2.0 mmhos/cm)
Sodium adsorption ratio, maximum:4.0 _
Available water supply, 0 to 60 inches: Low(about 4.6 inches)
Interpretive groups
Land capability classification(irrigated): None specified
Land capability classification(nonirrigated): 3w
Hydrologic Soil Group: C/D
Forage suitability group: Sandy over loamy soils on flats of hydric or mesic
lowlands(G156XB241 FL)
10
a
Custom Soil Resource Report
Other vegetative classification: Sandy over loamy soils on flats of hydric or mesic
lowlands(G155XB241 FL), Slough (R155XY011FL)
Hydric soil rating: Yes
Minor Components
Malabar
Percent of map unit:6 percent
Landform:—error in exists on—
Landform position(three-dimensional):Tread, dip,talf
Down-slope shape:Concave, linear
Across-slope shape:Concave, linear
Other vegetative classification: Sandy soils on flats of mesic or hydric lowlands
(G155XB141FL), Slough (R155XY011FL)
Hydric soil rating. Yes
Wabasso
Percent of map unit:5 percent
Landform:Flatwoods on marine terraces
Landform position(three-dimensional):Tread,talf
Down-slope shape: Linear
Across-slope shape: Linear
Other vegetative classification:Sandy soils on flats of mesic or hydric lowlands
(G155XB141FL), South Florida Flatwoods(R155XY003FL)
Hydric soil rating. No
Valkaria
Percent of map unit:2 percent
Landform: Drainageways on flatwoods on marine terraces
Landform position(three-dimensional):Tread,talf, dip
Down-slope shape: Linear
Across-slope shape: Linear, concave
Other vegetative classification:Sandy soils on flats of mesic or hydric lowlands
(G155XB141FL), Slough (R155XY011FL)
Hydric soil rating: Yes
Brynwood
Percent of map unit:2 percent
Landform.Flatwoods on marine terraces
Landform position(three-dimensional):Tread,talf
Down-slope shape: Linear
Across-slope shape: Linear
Other vegetative classification: Sandy soils on flats of mesic or hydric lowlands
(G155XB141FL), South Florida Flatwoods(R155XY003FL)
Hydric soil rating: Yes
11
'�'�Ob9
Gf;; Ron DeSantis
Mission.
Tq$otect,promote&improve the health i Governor
�of all people in Florida through integrated � Yi`
tate,county&community efforts. O A Scott A.Rivkees,MD
RECEIVED HEALTH State Surgeon General
Vision:To be the Healthiest State in the Nation
St.Lucie county
Per
Permltiing �
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-WELLSe-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 SLCDOHSLCDOH-WELLSAFLHEALTH.GOV
• Submit revisions to permit and/or site map 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
Location:3855 S US Highwayl,Fort Pierce,FL 34982
Mailing:5150 NW Milner Drive,Port St.Lucie,FL 34983 Accredited Health Department
Phone 772-873-4931 EPublicHealthAcc reditation Board
Fax 772-595-1306
FloridaHealth.gov
STATE OF FLORIDA PEIRR(Vtrl"AF�VLIQ R.UCT,
REPAIR,MODIFY,OR ABANDON A WELL Permit No. �59-3�4O..
Florida L)ninup ID__�
i,'-1 3outhwest PLPASE FILL OUT ALL APPUCABLIi,FIFLOS
I"Northwast ('Denotes Required Fields Where Applicable) Pormit Stipulations RGquired(Sao Aftcbod)
�St.Johns River rho tystior vloll wn(ruav au iownsliVo lot uomplerIng
XSouth Florida thla form and tc;nvord[r),qlhoPcnnitaPPIIO&tlon to Ina 62.52d(livid No.
03uwannee River Dppropdata dolopoted oudioMy whore apolluablo.
Wvt DDEP CUPIWLIP Application No
0 Oelegated Authority(If Applicable).
In + ChP�!�'` ,LffYW-,- .................. ....k16.......
1 j�LJ
a gal N Itn dre$ 'State *ZIP 'Teloplione Number
'Well Location..Address,Road Naine or-Nil T b 6
2. P(I Co1)"J,I k -r
�yo—C�
— /" — -9— t a
'.0wrZol 15 p,(PIN)orAltern K (Circle O.V Lot Block Unit
:21 q
4. & .0
64dlon or'-G-`ndG-ro*r,;-t- wa-lige Ycounty Subdivision- Chech If 62-PA4;--yes -D�l
qlL_ lei
'water well Contractor 'telephone or E-mail Address
f License Number
0 G
lWater Wall Contractor's Address Cil state
7. Type of Work;.,�&Construction ....Abrindonmont
8.'Number afProposed Wells
9.'Specify Intended Uso(s)of Well(s):
-X-Porriestic __ Landscape Irrigation ,_____Agricultural Irrigation _Site Investigation
Bottled Water Supply Recreation Area Irrigation _Livestock —Monitoring
OCT
ibftWater Supply(Limited Use/001-0 Nursery Irrigation .Tast
Commerciallindustrial Geothermal
Public Water Supply(Community or Non-CommunilyIDEP),--Golf Course Irrigation HVAC Supply OCT 1 3 2021
Class I InloollQ11 --FIVAC Return
Class V Injection: RechargeCommercial/Induvrial Disposal Storage and Reoovefy.. F1 I OH In St Lucie Jou
Remediation: Sparge _Other(vae(ibu) ft, , n
-EN I H
Othor IIII(od by a 01voll pornillong authnay)
10,,olstanco from Septic System if s2oo ft.. Ii.Facillt Description 12.C-stirriated$tail Date
T
��Jt. 'Primary Casing D m
13,%stimated Well Depth 10 'Estimated Casing 0000I.R lam.t. in. Open Hole: From.
14.Estimated Screen Interval:From-f�D—To 100 ft.
15.1primary Casing Material: Black Steel Galvanize(] Pvc; Stainless Steel
Not Cased ___Other:__
16.Secondary Casing, -_Telescope Casing __Liner _Surface Casing Diameter in.
17.Secondary Casing Material-. Black Steel Galvenized ---PVC --Sialnless Steel Other_____
ie*Method o(Construction,Repair,orAbandonment: Auger _CableTool __--jetted
X-yzotary _ Sonic
Combinaiton(Two or More Methods) Hand Driven(Well Point,Sand Point) .-_Hydraulic Point(Direct Push)
Horizontal Drilling ____,Plugged by Approved Method
19.Proposed Grouting iterval for the Primary,Secondary,and Additional Casing:
FromQ Grouting
Sea Material —Benton iIe__>!LNeat Cement Other'..-
From-—_—Tb--8eZ (—
Material I--BuntonItet..,,!4eSt Cement----Olhor
From TO Seat Material Neat Cement------Qlher. +
From +'- To�'~�Sesl Material Bentanite-Neat Cement Other
120.Indicate total number of existir!9 wells on site- -- Litsl number of existing unused walla on site
21,11s this well or any existing well orwater withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit(CUP/WUP)
orCUPNVUPApplicallion? Yes �No If yes,complete MO tollowing:CUPIWUP District Well ID No.—_
22,Latitude Longitude
23.Date Obtained From:__--jGPS Xmap -_,__-Survey Datum:NAD 27 NAD 83 WGS 84
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of= imitu.ynemrvi.nso nh&n w wo 1w,nimamd imr ia(Anuwaimiara of%op Nnfia SLItI406,141VIAIJIM drOKIPOIfy ArLIM611 U WAII:W 04"IfY U141 I AM
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Approval Granted Issue Date( Exrlraiion Date Hydrologist Approval
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THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED orFIcER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION,REPAIR,MODIFICATION,OR ABANDONMENT ACTIVITIES.
DPP Form 62,532.900(1) incotpotatodin62.632.400(l).F.A.C, Ffloeilvor),itn.,Octol)or7.2010 Page 1 of 2
SURVEYOR'S NOTES DESCRIPTION•LOT 1 LEGEND
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