HomeMy WebLinkAboutWell Permit # 59-22752>F o tf .n,..Ait7 �,. PERMIT APPLICATION TO
CONSTRUCTo REPAIR MODIFY
OR ABANDON� „
A WELL
St. Luale County Health ibepartment 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: (772) 873-4893- - `-e ,
Well Permit M o� -
OSTDS Permit #:
Fee Amount:
Date Paid:-
CUP/WUP #:
i •r;l ,. ,
1. an A rta )Qr.-kSQn ke ad" Q Ale Fi�,`eNc Fc. i9�� S6! 9Z9 6Fr�
Owner. or egal Nam of Property Owner Owner Mailing Address City !State Zip Owner Phone No.
2. 0 r G +'ra Q.
Well, Location (Street Address and Directions)
3. City / Zip
4esCrip ion S�division Name, Block No., Lot No.) Latitude / Longitude Section / Township / Range
fJnn1j s r-- l %erce Well Drilling Contractor Driller Mailing Address City !Stale Zi
P Driller Phone No. Driller Fax No.
5••• PROPOSED WELL: New El ••••• ••• ,.LVJ"Abandonment❑ Repair ❑ Other:•••••••••••••••••••••••••••••••••••••••••••••••
:
<, .
s' WELL TYPE: 19791ingle Family Drinking ❑ Single Family 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- Qt
............................................................................................. y......... li '1 '�",i,N WNM41A 43
......................... ........ .....hi
..........
!• SITE IS ON: ❑ SEWER SEPTIC PROPOSED DISTANCE TOO OSEST SEPTIC'ORTJiTLEWER LI qE:
$• CUP/WUP: Is a Water Use Permit (WUP) required? ❑ YES (If YES WUP must 1961aald)w
9• CONSTRUCTION METHOD: ❑ Rotary �❑ ble Tool ❑Other (Explain):
lJ
10. GROUTING METHOD: ❑Bentonite Cement ❑ ther (Explain
O
11. WELL CONSTRUCTION: ❑PVC ❑ Blk-Steel Galvanized ❑Other (Explain):
12• CASING DIAMETER (SIZE): Z 13. ESTIMATED:. TOTAL DEPTH "SCREEN INTERVAL FROM TO
•••••••••••••••••••••••••.••........................
.........................................................................................................................................
4. PERMIT CONDITIONS:
♦ Contact St. Lucie County Health Department (SLCHDI the day before Initiating drilllna or abandonment operations and provide the driller name,
permit number, and estimated time drilling or abandonment will begin (Please contact an Inspector dlrectiv 24 hours prior to drilllna all public drinkina
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 during drilllna or abandonment operations
..... •..................................................................
15 atWer ELL e perCOmit aNrtRACTOR PERMIT AGREEMENT:r.............................................................................
-I herby certify that I will comply with the applicable rules of Title 40, Florida Administrative Code, and that OWNER/AGENT PERMIT AGREEMENT:
rechargeficial 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-8, FAC, and 8Y-532, FAC, will be maintained. If above setbacks cannot be maintained a variance Chapter 373, Florida Statutes, to maintain or properly abandon this
application will be applied for and obtained prior to drilling. I further certify that all information provided on I well; or. I clarity that I am the agent for the owner, that the information
this application is accurate and that 1 will obtain necessary approval from other federal, state, or local provided ' a e, t h informed the o er of his
go ants. Well com letion reports must be submitted to the District and the delegated agency within - re sibllities as slat a O er.con personnel of the
d s er drilling %�pertnit expiration, whi ever occurs first OH or esentati
SignatMWell Contractor
ZG
License No.
A -� 7 .— /2
Date it Own or e
9
> _ �Z
i 9 ure Date
........
EWRST N D j YOWHTOR THIS
••••••• PERMIT IS•NOT VALI UNTIL PROPERLY ................ ............................
OFFICERIORR OFMC71AL USE REPRESENTATIVE OF
PERMIT I
THIN T. LUCIE
ALID FOR 18 DAY3 FROM ATE OF ISSUANCE
COUNTY HEALTH DEPARTMENT.
Permit Approved By:
' C //
� t
Issue 2
.........................PRINT
Distance to closest septic system
NAME _ _ —
or sewer line:
_ _ _ _ _ _ _ _ _ _ _ SIGNATURE
Date
....
Weil Construction Method:
Grout Material:
Inspectors Comments:
'LC HD Rev 7/13/07-
Approved By:
Date:
SIGNATURE
SUPERVISOR REVIEW: