HomeMy WebLinkAboutWell Permit # 59-22743PERMIT APPLICATION TO
CONSTRUCT, REPAIR, MODIFY,[Date
ermiWM:
S PeOR
ABANDON A WELL
mou
-St. Lucie County Health Department This form must be completed by the
aid:
Environmental Health, ; Water Programs certified well contractor for approval
UP #:
51 SO& Milner Oriv®'Port St: Lucie, FL 34983 prior to well construction. ?
Phone: 772 873-4931...Fax: 772 873-4893
1_, ra° ) ".0-K50e1 y6Y0 Arca.d: c, Ave', El FL 3! `rrJ o S6/ 9 _T
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r gal N e of Property Owner Ow r Malting Add City / State Zip Owner Phone No
r . ai in
2. ( e In 3 Y�96C
Well Location (Street Address and Directions)
3.
Ct / Zip
e D^y�'�cription'(Subdivision Name, Block No., Lot No.) f Latitude / Longitude
Secti n / Township /
Range
Well Drilling Contractor Driller Mailing Address City /State
.r
Zip Driller hone No.
Driller Fax No.
...❑.Other....'...•
•.57...PROPOSED WELL: ❑
...❑.Replacement
.............••.•......,.•.............
New tad"Abandonment....❑Repair
...........................,......'..............,.....•...............•........•......
WELL TYPE: SingleFamily Drinking❑SingleFamily Irrigation
, ............•.....
❑ DOH Public Drinking (>Duplex/ < 15 Service Connections/Serves less than 25 people/ or Business does not consume water) - WUP Required
❑ DEP Public Drinking (> 15 Service Connections or Serves 25 people or more) - WUP Required
❑ Commercial Irrigation - WUP Required ❑ Monitor - Qty ❑ Other (Explain):
. _.I ......�,.
.7. SITE.IS.ON:.❑.SEWER...EffrFSEPTIC....PROPOSED DISTANCE TO CLOSEST SEPTIC 0.........�.. IN
8. CUP/WUP: Is a Water Use Permi (WUP) required? ❑ YES ENO (If YES WUP mLI c ed)
9• CONSTRUCTION METHOD: Rotary ❑ Cable Tool ❑ Other (Explain): JUL 0 2 2012
t 10. GROUTING METHOD: ❑Bentonite Cement ❑ Other (Explain): Iv e
11. WELL CONSTRUCTION: LYI PVC ❑ Blk-Steel ❑Galvanized ❑ Other (Exp a•Sy7t� Lpuc►e nnFf�►; AL HtFL� `-i DIVISION
��VVT1 t�
12. CASING DIAMETER ,(SIZE):............13:... ESTIMATED: TOTAL DEPTH 2PSCREEN ,INTERVAL .FROM
.......,. TO.........
14. PERMIT CONDITIONS:
♦ Contact St: Lucie County Health Department (SLCHDI the day before Initiatina 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 available at the well site durina drilling or abandonment operations —
.......................................................... :........................................ .................. ............................................................................
15. WELL CONTRACTOR PERMIT AGREEMENT: OWNER/AGENT PERMIT AGREEMENT:
I herby certify that I will comply with'the applicable rules of Title 40, Florida Administrative Code, and that I certify that I am the owner of the property, that the information -
a water use.permit or'artificial recharge permit, if needed, will be obtained prior to commencement of well provided is accurate, and that I am aware of my responsibilities under
constructlon. I also certify that all setbacks referenced in Rule 40E-3, Florida Administrative Code (FAC), ; Chapter 373, Florida Statutes, to maintain or properly abandon this
84E-8, FAC, and 82-532, FAC, will be maintained. If above setbacks cannot be maintained a variance ' well; or, I clarify that I am the agent for the owner, that the information
application will be applied for and obtained prior to drilling. I further certify that all information provided an ; provided is accurate, gadtbak I have informed the owner of his
this application Is accurate and that I will obtain, necessary approval from other federal, state, or local ; responsibilit s at . w r nsents to personnel of the
g enis. Well completion reports must be submitted to the District and the delegated agency within DO re rese ccess 11 site.
0 da after drilling or rmit expiration, whichev r pccurs first '
— Z
of Well Contractor License No.
..............................
THIS PERMIT IS NOT V
Permit Approved By:
Date
Date
SLEONLY............................................
OF TH ST. LUCIE COUNTY HEALTH DEPART M NT.
U C ,
fr
Issue Date: '
_PRINT NAME .—._....... ...........,SIGNAT v _— — — — — — — — — — — — ——.---------.
Distance to closest septic system or sewer line: Well Construction Method: Grout Material:
NOT WRITE BELOW THIS LINE - FOR
PROPERLY SIGNED BY AUTHORIZED OFFICER OR R
Inspectors Comments:
Approved By: Date:
SLCHD Rev 7/13/07 SIGNATURE
SUPERVISOR REVIEW: