HomeMy WebLinkAboutPermit Application New WellSTATE OF FLORIDA PERMIT APPLICATION TO CONSTREICT, Permit No., - 3_
e REPAIR, MODIFY, OR ABANDON A WELL Septic No.
- ❑ Southwest Permit Stipulations Require
❑ Northwest THIS FORM MUSTBE FILLED OUT COMPLETELY.-
_ ❑ St. Johns River The water welt confiactoris responsible forcompleft this 62-524 well ❑
+y wec- ❑ South Florida form and forwarding the penrli to the appropriate delegated ctlpf
❑ Suwannee River county where appricaWe- wup Application No.
.CHECK BOX FOR APPROPRIATE DISTRICT = L ► : a ..
. btepnen vale PSL 34952 772.283.6452
3. St Lucie Pump & Water Supply, Inc. 1452 772 287 0233
Well Drilling Contractor License No. Telephone No. Nw NE
594 SE Monterey Rd. 4. r of m of Section 18
Address rr. ds1�
Stuart FL 34994 36S (Indicate Well an Chart)
5. Tcvnship Range" 41E
-City. State Zip
s. St Lucie None - 2 j NA ( NA
County SubdiVislon Name Lot Block Unit
7. Number of proposed wells 1 Check the use of well: X Domestic (Res. Home) , Monitor , Irrigation (Residential)
=, Irrigation (Business) _ Public Water Supply (Business) List Other_
Distance from septic system 75'+ ft. Distance from foundation 25' ft.
Estimated start of construction date 8-15-06 Plumbing connection:
8. Application for. X New Construction Repair/Modify
Abandonment (Reason for abandonment
S. Estimated: Well Depth 131+' Casing Depth 130+'
Screen Interval from U - to 'Casing Material: Blk-Steel Im PVC
Casing Diameter 21, Seal Material' Cement—
10. If applicable: Proposed From to Seal Material
Grouting interval From to Seal Material
From to Seat Material
11. Telescope Casing X or liner (check one) Diameter 211
Blk-Steel / Galvanized PVC Other (specify):
12. Method of Construction: . Rotary X. CableTeol Combination
Auger Other (specify):
13. Indicate total No. of wells on site 0 . List No. of unused wells an site 0
14. Is this well or any other well or water withdrawal on the owner's contiguousq,qperty covered under
a ConsumptivePNater Use Permit (CUP/WUP) or CUP/WUP Apprimflon? A No Yes
(if yes, complete the following) CUP/ WUP No.
District well ID No.
Latitude Longitude
Data obtained from GPS —or map _ orsurvey _ (map datum NAD 27 _NAD 83 __j
Description of facility House
_Sewer -X�Sep.tic
LEI
O NTY HEA TH DEPARTMENT
a of �e� (l/denlify oRaces
15. ! DereL7 m6fy o>al l,ra cCrtgly With Uie apprcabb ndas orllfe 40, EkddakSTiiesve Code 1
=212'atarathe awnerCf
and that2wdter= Para crxW21reehalgaPem'+tlfnesded,basbworwill beobtiined
prlorba7mm�eherddwegeonshuctlaa lfuclhereutifytlialalllnfoim�5onPmNdedonMis ft nV2 br ft otw,didth
890=50n is D=wrz and that I W3 ob ' approval from 09V redrrar, state, or beat as d abatis
)9
Cab, I aPyi0Ne l agree tb aweg aompleEan mpadb the DitSdWWn 30 days
aPxdiEingOt P+� NO a== ftL
1452 Y
Approval Granted By:
-y,
See Attached Survey"
south
in&ed'asaeaaafe,attdd0Iamawareoraq
orFV,P syabandonfNsweka,Iaerbyftmtlam
aril tliat I Aava lnrpaxd the awnerar>ris rr
NWW ara iepresemal m access b tlm wd s�L
6 2.
-- D to
Hydrologist Approval _
Owner Number. V Feelweceived: $ •Receipt No.- Check No
Inspected by: ff
Date:
THIS PERMIT is NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OFTHE WMD/CHD. IT B AILABLEAT
THE WELL SITE DURING ALL DRILLING OPERATIONS. THiS PERMIT. IS VALID FOR 180 DAYS. FROM DATE OF.ISSUANGE.
Form 0123 to
i
Issue Date: