HomeMy WebLinkAboutPermit Application SewageApr 26 12 07:56a A @ C Welldrilling Inc
772-465 9502 p•2
FLORWA t7!-^�tARrtr¢N[ OF PERMIT APPLICATION TO
HEA T
CONSTRICT, REPAIR, MODIFY,
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. Lurie, FL 34983 prior to well construction.
Phnnu• 1771% 070 A— -__ - . _-- -
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0:,nur, or Legal :Ili ne c` RMPer.,- O: i Ills /i9 o/i pc�
2. - /- _ •;rc;r O.,.r�arh7ailir•; Adds;..
SlC � rd'1alLu Location tre l [ Ci on_�r� Q�
3.
Lei;,/ Cr-ccr�s:'r]r. f�uhdivE,ion Name. Blw.h No.. Lo: '1Z,I
,Latiiucc : Loncit
4. l;-i �� aIS' j -ll %�;���diVG- O1•'� /i-1UCIt�r>Q., Milwo
Well Permit #: �� s!
OSTDS Permit
Fee Amount:
Date Paid:
CUP/WUP #:
+•/: $Etter L.p
.................................................... ......... _ _.r �,nnci na,:nt:i3O. UIaI•r��'iX I:o.
S. PROPOSED WELL...............................................................................................................................
._„• : KNew ❑ Replacement ❑ Abandonment ❑ Repair ETOther:""
......................................................................... _
6. WELL TYPE: Single Family. Drinking .... El Single Family Irr"-..'.•.,.'....................... ...
❑ DOH Public Drinking ( Duplex/ < 15 Service Connecdcns/Serves less than 25 people/ d t co u
El - UP R iced
DEP Public Drinking (' 15 Service Connections or Serves 25 people or more) - WUP R uire
❑ Commercial Irrigation - WUP Required.,• ❑ , Monitor , Qty.•......,.-...'.•. ❑ Other (Explain
................................................... .....
..................................... :.......................
7. SITE IS ON: SEWER SEPTIC -PROPOSED DISTANCE TO CLOSEST SEPTIC OR PUBLIC SEWER LINE: Jr
6• CUP/WUP. Is a Water Use Permit (WUP) required? ❑ YES 0 NO (If YES WUP must be attached)
9. CONSTRUCTION METHOD: EgRotary ❑ Cable Tool ❑ Other (Explain):
10. GROUTING METHOD: ❑Bentonite ®Cement ❑Other (Explain):
11. WELL CONSTRUCTION: ®PVC ❑Blk-Steel ❑Galvanized. ❑ Other (Explain):
.12..CASING . DIAMETER . . (SIZE). : ....13. ESTIMATED: TOTAL.DEPTH SCREEN INTERVAL FROM LQ TO
...................................................... ...................................................
14. PERMIT CONDITIONS:...................................................
Contact St. Lucie Catrnty Haalth nanA..--4.,fcr
permit number,. and estimated time drilling or abandonment will begin Ple„se
waiter wells)_ If construction does not occur and SLCHD is not notified and an
fee will be assessed.
time, a reinspection
De lied Slte Ian u 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 Ronda Administrative Code.
This permit muldt be available at the well site during drl Ilina or abandonment oneratfons.
15.... ................................................................
. WELL CONTRACTOR PERMIT AGREEMENT: r•.•••••••••.•••......••'••••••••••••.•.•••••••••••••••••••••••.•••••••••••••
' OWNERiAGENT PERMITAGGREEMENT:
I herby certify that 1 wig omnpty with the applicable Hiles of Tole 4e, Florida Administrative Code, and that a water use permit or artificial recharge permit, if needed, will be obtained prior to commencement of well 1 canny that 1 am the owner of the property, that the information
on
t3, FAC,
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
arid b2-532. FAC, will be maintained. If above setbacks cannot be maintained a variance Chapter 373, Florida Statutes, to maintain or property abandon this
application will be applied for and obtained prior to drilling, 1 further certify that all Information provided on wet 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 c provided b accurate, and that I have Informed the owner of his
govemm We0 cofplior, reports must be submitted to the District and the deregated agency witnin responsibilities as stated above. Owner consents to personnel of the
30 days adrilling orermtt expiration, whichever occurs first, r DOH or a representative access to the well Site,
C
V,
Signature Well Contractor License No. Date Owners or Agents Signatu Date
•••- ••• - •- •--••••-•- ........DO NOT WRITE BELOW THIS LINE — FOR OFFICIAL USE ONLY... ..................................._....,
THIS PERiAIT IS NOT VALID UNTiL PROPERLY SIGNED BY AUTHORIZED OFFICER OR REPRESENTATIVE OF THE ST. LUCIE COUNTY HEALTH DEPARTMENT.
J PERMr r IS VALID FOR 180 DAY FIRDATE O ISSUANCE
Permit Approved By: A
.................... _ _ PRINTMAittE Issue Date: r ft Z/
,—,_ _._. _ _ _ _ —RE
Distance to closest septic system or sewer line: Well Construction Method _ — — --------
Well
Grout Material -
Inspectors Comments-.
Approved By:
SIGNATURE
Date: