HomeMy WebLinkAboutWell Permit # 59-22714It Oak. 0 lrr ,, - PERMIT APPLICATION TO
CONSTRUCT, REPAIR, MODIFY,
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OR ABANDON A WELL
St. Lucie County Health Department This form must be completed by the
Environmental Health - Water Programs certified well contractor for approval
5150 NW Milner Drive Port St. Lucie, FL 34983 prior to well construction.
Phone: (772) 873-4931 Fax: (7721 873-ARWA
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2. Own oAegal N of Property Owner
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Owner Mailing Address
Well Permit #: 2 o 2-7)
OSTDS Permit
Fee Amount:25
Date Paid:
CUP/WUP #:
City / State Zip Owner Phone No
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City / Zip
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I Descnptl (Su vision Name Block No , Lot No) Latitude / Longitude S lion / Township I•Ran�e,
Well Drilling Contractor -Driller Mailing ddre City /.State Zip Driller Phone No. Driller Fax No
..5:... ��Replaciment
.:.............. ................................................................................
PROPOSEDWELL .flew ❑ Repair ❑ Other:
.................................. �.::............................. .................................................................................
..... .. .
'ML 15
s• WELL TYPE: Single Family Drinking ❑ Single Family Irrigation ;
❑ DOH Public Drinking (>Duplex/ < 15 Service Connections/Serves less than 25 people/ or Business does not con metwf�er7WVt1P Required
DEP Public Drinking (> 15 Service Connections or Serves 25 people or more) - WUP Required J �- Q6,R1101
❑ ❑ ( ®�1�� O H p1�1S10N
Commercial Irrigation - WUP Required Monitor-
............................ ........................................................ Other W0A KI
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7• SITE IS ON: L`J SEWER l SEPTIC PROPOSED DISTANCE T LOSEST SEPTIC `PUBLIC SEWER LINE:
$• CUP/WUP: Is a Water Use Permit (WUP) required? ❑ YES 0 NO (If YES WUP must be attached)
9• CONSTRUCTION METHOD: ❑ Rotary ❑ Cable Tool El Other (Explain):
10. GROUTING METHOD: ❑Bentonite ❑ Cement Other (Explain):
11. WELL CONSTRUCTION: ❑PVC ElBlk-Steel Galvanized ❑ Other (Explain):
12. CASING DIAMETER SIZE .13. ESTIMATED: TOTAL -DEPTH 12-6
SCREEN INTERVAL FROM TO
........ (SIZE): ....................................... ,...................................................................................
14.PERMITCONDITIONS:....
♦ Contact St. Lucie County Health Department (SLCHD) the day before initiating drilling or abandonment operations and' provide the driller name,
permit number, and estimated time drilling or abandonment will begin (Please contact an Inspector directly 24 hours prior to drilling all public drinking
water wells). If construction does not occur and SLCHD is not notified and an SLCHD Inspector visits the site on or after the estimated time, a reinspection
fee will be assessed.
♦ Detailed Site plan must be attached and show the proposed well location and distances to onsite building structures, property lines, all onsite and
neighboring septic systems and/or sewer lines or sewer systems, and all other applicable setbacks per Florida Statutes and Florida Administrative Code.
.♦ . This permit must be avallable at the well site during dNllino or abandonment operations
.....OR......P........................................................................ .•...••
1 a. WELL CONTRACTERMIT AGREEMENT: ""••"'•"""""""...... "
OWNER/AGENT PERMIT AGREEMENT:
I herby certify that I will comply with the applicable rules of Tltle 40, Florida Administrative Code, and that
a water use permit or artificial recharge permit, If needed, will be obtained prior to commencement of well I certify that I am the owner of the property, that the Information
construction. I also certify that all setbacks referenced in Rule 40E-3, Florida Administrative Code (FAC), , Provided is accurate, and that I am aware of my responsibilities under
e4E-e, FAC, and 82-532, FAC, will be maintained. If above setbacks cannot be maintained a variance j Chapter 373, Florida Statutes, to maintain or property abandon this
application will be applied for and obtained prior to drilling. I further certify that all information provfded on well; or, I clarify that I am the agent for the owner, that the Information
this application is accurate and that I will obtain necessary approval from other federal, state, or local Provided Is accurate, and that I have Informed the owner of his
governments. Well completion reports must be submitted to the District and the delegated ag ncy thin _' re, ��des a ti+o.-owner consents to personnel of the
0 s after drilling or ermit expiration, w i eve occurs, firs . "" , or a rep ccess II site.
Sig re of Well Contractor License No. , Date ;.OGvners nts Signature Date
••••••••••••••••••••••• ...............DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY............. .
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AUTHORIZED OFFICER OR REPRESENTATIVE OF THE ST. LUCIE COUNTY HEALTH DEP • TMENT.•
PERMIT IS VALID FOR D S FROM DATE UANCE
Permit Approved By: . . P Issue Date.?
—.—._.—._..._. —. —. — PRINT N. .AME _ _ _ _ _ _ gl --
Distance to closest septic system or sewer line: Well Construction Method:
Inspectors Comments:
--------------------------------
Grout Material:
3LCi-iD Rev 7/13I07 Approved By: SIGNATURE ' Date:
SUPERVISOR REVIEW: