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HomeMy WebLinkAboutOSTDS Newr STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS New APPLICANT: (St Lucie Habitat for Humanity, Inc) PROPERTY ADDRESS: 7508 Coquina Ave Fort Pierce, FL 34951 LOT: 5 BLOCK 79 SUBDIVISION: Lakewood Park PROPERTY ID #: 1301-607-0226-000-0 PERMIT #:56-SF-1779638 APPLICATION # : AP1300986 DATE PAID:. FEE PAID: RECEIPT #: DOCUMENT # : PR1071527 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic new CAPACITY A [ ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ 7 D [ 500 ] SQUARE FEET Drainfield new SYSTEM R [ ] SQUARE FEET N/A SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [x] MOUND I CONFIGURATION: [ ] TRENCH [x] BED [ ] N F LOCATION OF BENCHMARK: site BM NiD CL of Rd SE property corner I ELEVATION OF PROPOSED SYSTEM SITE 'E BOTTOM OF DRAINFIELD TO BE L D E O T H E R [ 1.00 ] [INCHES FT ] [ABOVE BELOW ] BENCHMARK/REFERENCE POINT [ 3.00 ]I INCHES FT.]I ABOVE BELOW] BENCHMARK/REFERENCE POINT L REQUIRED: [ LU.UU] INCHES EXCAVATION REQUSREU: L 1 Lmt-nmo ie system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of '0 gpd. ie licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with 64E-6.013(3)(f), FAC. SPECIFICATIONS BY: Brian J Ingram TITLE: Environmental Specialist II APPROVED BY: LE: Environmental Specialist II St. Lucie CHD Brian J Ingrpff DATE ISSUED: 08/04/2017 EXPIRATION DATE: 02/04/2019 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 v 1.1.8 AP1300986 SE1043240 r ®� rl NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. +'l€' St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 HEALTH PAYING ON: PERMIT#: 56-SF-1779638 BILL DOC#:56-BID-3490563 CONSTRUCTION APPLICATION#: AP1300986 RECEIVED FROM: St Luice Habitat for Humanity, Inc AMOUNT PAID: $ 515.00 PAYMENT FORM: CREDIT CARD PAYMENT DATE: 07/27/2017 • MAIL TO: (St Lucie Habitat for Humanity, Inc) FACILITY NAME: PROPERTY LOCATION: 7508 Coquina Ave Fort Pierce, FL 34951 5 79 Lot: Block: Property ID: 1301-607-0226-000-0 EXPLANATION or DESCRIPTION: QUANTITY FEE 128 - OSTDS Construction System Inspection Research Fee -1 - Surcharge (All) -1 - OSTDS New Permit Surcharge '-1 - OSTDS Construction Application and Plan Review,New 123 - OSTDS Construction Site Evaluation 126 - OSTDS Construction Permit (New or Mod, Amendment) 127 - OSTDS Construction System Inspection 133 - OSTDS Construction Reinspection 1 $ 5.00 1 $ 15.00 1 $ 100.00 1 $ 100.00 1 $ 115.00 1 $ 55.00 1 $ 75.00 1 $ 50.00 RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-3307718 OVIJ 5C _ 2 e -7-7 S [{lE STATE OF FLORIDA PERMIT NO. ' DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: % SYSTEM RECEIPT #: "s APPLICATION FOR CONSTRUCTION PERMIT APPLICATION FOR: [V/] New System [ ] Existing System [ ] Holding Tank [ ] Innovative [ ] Repair [ ] Abandonment [ ] Temporary [ ] APPLICANT: St. Lucie Habitat for Humanity, Inc. AGENT: St. Lucie Habitat for Humanity, Inc. TELEPHONE: 772-464-1117 MAILING ADDRESS: 702 South 6th Street, Ft. Pierce, FL 34950 �-77 2� 57 70 0 O 9 TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR -PLATTED (MM/DD/YY) IF' REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION LOT: 5 BLOCK: 79 SUBDIVISION: Lakewood Park Unit? PLATTED: 1958 PROPERTY ID #: 1301-607-0226-000-0 ZONING: RS-4 I/M OR EQUIVALENT: [ No ] PROPERTY SIZE: .230 ACRES WATER SUPPLY: [v/] PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ] DISTANCE TO SEWER: FT PROPERTY ADDRESS: 7508 Coquina Avenue, Fort Pierce, FL DIRECTIONS TO PROPERTY: Fron the intersection of Emerson Road and North Blvd„ east to Woodsmere Way, south to Coqud East on Coquina, lot is on the north side BUILDING INFORMATION [V, RESIDENTIAL [ ] COMMERCIAL Unit Type of No. of Building Commercial/Institutional System Design No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC 1 Residential 3 1201 300 2 3 4 [ ] Floor/Equipme/71 Drains [ ] Other (Specify) 2 7. SIGNATURE: DATE: DH 40Vat' 9709 (Obsoletes previous editions which may not be used) %%�% Incored 64E-6.001, FAC P �of 4 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATION .APPLICANT: St Lucie Habitat for Humanity, Inc CONTRACTOR / AGENT: St Luice Habitat for Humanity, Inc LOT: 5 BLOCK: 79 SUBDIVISION: Lakewood Park ID#: 1301-607-0226-000-0 APPLICATION # AP1300986 PERMIT # 56-SF-1779638 DOCUMENT # SE1043240 • TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.23 ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ] AUTHORIZED SEWAGE FLOW: 345.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: 1200.00 SQFT UNOBSTRUCTED AREA REQUIRED: 750.00 SQFT BENCHMARK/REFERENCE POINT LOCATION: site BM NO CL of Rd SE property corner ELEVATION OF PROPOSED SYSTEM SITE 1.00 [ INCHES / FT ] [ABOVE / BELOW ] BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: FT DITCHES/SWALES: 90 FT NORMALLY WET: [ ]YES [X]NO WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 80 FT NON -POTABLE: FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 50 FT SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO] 10 YEAR FLOOD ELEVATION FOR SITE: FT[ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD GATT. DDAL+TT.F T14=n10 hrPTAN CTTF 1 ROTL PROFILE INFORMATION SITE 2 USDA SOIL SERIES:Lawnwood sand Munsell #/Color Texture Depth 10YR 4/1 Sand 0 To 11 10YR 5/1 Sand 11 TO 19 10YR 6/2 Sand 19 To 27 10YR 5/8 CMN/PRM RF 22 To 44 1 OYR 7/2 Sand 27 To 44 7.5YR 2.5/2 Spodic Material 44 To 63 10YR 2/2 Fine Sand 63 To 72 USDA SOIL SERIES:Lawnwood sand Munsell #/Color Texture Depth 1 OYR 4/1 Sand 0 To 6 1 OYR 5/1 Sand 6 To 20 1 OYR 6/2 Sand 20 To 33 1 OYR 7/2 Sand 33 To 47 1 OYR 2/2 Spodic Material 47 To 60 10YR 3/3 Loamy Fine Sand 60 To 72 OBSERVED WATER TABLE: 54.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ] ESTIMATED WET SEASON WATER TABLE ELEVATION: 22 INCHES [ ABOVE / BELOW ] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X]YES [ ]NO DEPTH: 22.00 INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [XI BED f REMARKS/ADDITIONAL CRITERIA Sand/0.60 DEPTH OF EXCAVATION: INCHES [ ] OTHER (SPECIFY) VSWT determined using USDA WSS and soil borings. OYR518 CMN PROM RF mottling in 10YR6/2 and 10YR7/2 matrix >2% starting at 22" in SB1. B1 V above BM. SB2 3" above BM. SITE EVALUATED BY: Ingram, Brian (TjWe: Environmental Specialist 11) (ENVIRONMENTAL HEALTH) DH 4015, 08109 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC DATE: 08/04/2017 Page 3 of 4 AP1300986 EID1779638 v 1.0.2 STATE OF FLORIDA m DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS ,h DVS APPLICANT: St. Lucie Habitat for Humanity, Inc AGENT: Same • LOT: 5 BLOCK: 79 SUBDIVISION: Lakewood Park Unit 7 PROPERTY ID # : 1301-607-0226-000-0 [ Tax ID Number PERMIT # .5� -Sr- - 1 l7 F03 ; TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [✓] YES [ ] NO NET USABLE AREA AVAILABLE: ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [RESIDENCES-TABLEI ] AUTHORIZED SEWAGE FLOW: 1500 GALLONS PER DAY [ 1500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT BENCHMARK/REFERENCE POINT LOCATION: SE corner of lot, centerline of road (point 20007 ELEVATION OF PROPOSED SYSTEM SITE IS.18 [FT ] [ABOVE ] BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: n/a FT DITCHES/SWALES:n/a FT NORMALLY WET? [ I YES (✓] NO . WELLS: PUBLIC: n/a FT LIMITED USE: n/a FT PRIVATE: +75 FT NON —POTABLE: n/a FT BUILDING FOUNDATIONS: +5 FT PROPERTY LINES:9 FT POTABLE WATER LINES: n/a FT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [✓] NO 10 YEAR FLOODING? I ] YES [v/] NO 10 YEAR FLOOD ELEVATION FOR SITE: Zone X FT MSL/NGVD SITE ELEVATION: Zone 20.7FT MSL/N&iD NAvD SOIL PROFILE INFORMATION SITE 1 MUNSELL #/COLOR TEXTURE DEPTH TO TO TO TO TO TO TO TO TO USDA SOIL SERIES: SOIL PROFILE INFORMATION SITE 2 MUNSELL #/COLOR TEXTURE DEPTH TO TO TO TO TO TO TO TO TO USDA SOIL SERIES: OBSERVED WATER TABLE: INCHES [ABOVE/BELOW r] EXISTING GRADE. TYPE: [PERCHED /APPARENT ] ESTIMATED NET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: j ] YES [ ] NO DEPTH: INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] REMARKS/ADDITIONAL CRITERIA: SITE EVALUATED BY: BED DEPTH OF EXCAVATION: INCHES [ ] OTHER (SPECIFY) DATE: DH 4015, 08/09 (obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 3 of 4 Property Card Page Iof1 6&^ SF- 177�(.3 U 2 Michelle Franklin, CFA -- Saint Lucie County Property Appraiser -- All rights reserved. Property Identification Site Address: 7508 Parcel ID: 1301-607-0226- Account #: 1856 Sec/Town/Range: COQUINA AVE 000-0 02/34S/39E Map ID: 13/02N Zoning: RS-4 Use Type: 0000 Jurisdiction: Saint Lucie County Ownership Legal Description St Lucie Habitat For Humanity Inc LAKEWOOD PARK -UNIT 7- BLK 79 LOT5 (MAP 13/02N) 702 S 6th ST (OR 3997-2170) Fort Pierce, FL 34950 Current Values Historical Values 3-year Just/Market: $5,400 Assessed: $5,400 Year Just/Market Assessed Exemptions Taxable Exemptions: $5,400 Taxable: $0 2016 $5,400 $5,400 $5,400 $0 2015 $5,100 $4,840 $0 $4,840 2014 $4,600 $4,400 $0 $4,400 Date 02-21-2017 12-18-2015 10-15-2004 View: Year Built: N/A Primary Wall: Bedrooms: 0 Full Baths: 0 Half Baths: 0 Sale History Book/Page Sale Code Deed Grantor 3997 / 2170 0118 DE St Lucie County 3818 / 2182 0118 TD LePage Lucien 2081 / 1165 XX00 WD Schmelyum Jr,Donald E Primary Building Information Finished Area of this building: 0 SF Gross Area of this building: 0 SF Exterior Data Type Roof Cover: Roof Structure: Frame: Grade: Story Height: No. Units: 0 Interior Data A/C %: 0% Electric: Heated %: N/A% Heat Type: Sprinkled %: 0% Heat Fuel: Price $0 $5,300 $26,000 Building Type: Effective Year: 2014 Secondary Wall: Primary Int Wall: Avg Hgt/Floor: 0 Primary Floors: Total Areas Finished/Under Air 0 (SF): i` Gross Area (SF): 0 Land Size (acres): 0.24 Land Size (SF): 10,650 Total Building Count: 1 Special Features and Yard Items Qty Units Year Bit This information is believed to be correct at this time but it is subject to change and is not warranted. © Copyright 2017 Saint Lucie County Property Appraiser. All rights reserved. http://www.pasic.org/RECard/ 7/27/2017 ENGINEERS 0 SURVEYORS July 27, 2017 Habitat for Humanity To be picked up 5& - 5F- 17710 3 Survey Department 10250 SW Village Parkway, Suite 201 Port St. Lucie, FL 34987-2362 RE: 7508 Coquina Avenue, Ft. Pierce EDC Survey Project 2-17-245 Enclosed please find three signed, sealed copies of the boundary, topo, tree survey for the above referenced project, along with three copies of the site plan showing the proposed house, well and septic locations. Also enclosed is the Health Department Application for Construction Permit and Site Evaluation form and the SLC Vegetation Removal Application Please let us know if you have any questions or need anything further. Sincerely, Tiffany Owen Enclosures ENGINEERING DESIGN & CONSTRUCTIONM10 M CIVIL ENGINEERS & SURVEYORS SPECIALIZING IN LAND D -- LR! P N. 10250 SW Villaae Parkway. Suite 201 • Port St. Lucie • FL • 34987-2362 • 772-419-8383 • 772-408-4208 Fax info@edc-inc.com STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, ���� REPAIR, MODIFY, OR ABANDON A WELL Permit No. 79 EOA ❑ Southwest Florida Unique ID PLEASE FILL OUT ALL APPLICABLE FIELDS ,f r ❑ Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required (See Attached) 0 St. Johns River m The water well contractor is responsible for completing ❑South Florida this form and forwarding the permit application to the 62-524 Quad No. Delineation No. ❑ Suwannee River appropriate delegated authority where applicable. ❑DEP CUP/WUP Application No. ❑ Delegated Authority (If Applicable) ABOVE THIS LINE - FOR OFFICIAL USE ONLY 1.5'�GU�.rF f�i��r/,% T�/�1U/►+i%(/%�/ 70a .57 ­3&0`/7 77,,�.5-77 GC,,o&, 'Owner, Legal Name if Corporation 'Address "City "State -ZIP 'Telephone Number `Well Location -Address, Road Name or Number, City 3. /901-- 607 -- © A�6 000 -- 0 _ S `Parcel ID No. (PIN) or Alternate Key (Circle e1 Lot a. 3 �%S 3 S %r Section or Land G�rj�j�nt� r ,w,ans I `Range 'Count Subdivision 0�/Yi�/��'Y��j% ���7 79 � Block Unit Yes —No -Water W II Contractor -License Number 6. V/ , 3 C't'1 S "Water Well Contractor's Address 'Telepho e umber B ��G City E-mail Address State 5 ZIP 7. 'Type of Work: _NZ Construction _Repair _Modification _Abandonment 8. 'Number of Proposed Wells 'Reason for Repair, Modification, or Abandonment 9. -Sp y Intended Use(s) of Well(s): /h\ om'n-m�ent t J_Domestic _Landscape Irrigation _Agricultural Irrigation _Site Investigation L�� _Bottled Water Supply _Recreation Area Irrigation _Livestock _Monitoring _Public Water Supply (Limited Use/DOH) —Commercial/Industrial Nursery Irrigation _Test -Coupled Geothermal AUG 4 2011 _Public Water Supply (Community or Non-Community/DEP) _Golf _Earth Course Irrigation _HVAC Supply _Class I Injection _HVAC Return Class V Injection: _Recharge _Commercial/Industrial Disposal _Aquifer Storage and Recovery _Drainage DOM On St Lucia Cel Remediation: _Recovery _Air Sparge _Other (Describe) _--,_ F VIR01MENTA 4 HE _Other (Describe) (Note: Not all types of wells are permitted by a given permitting authority) 10.`Distance from Septic System if <_200 ft. 11. Facility Description A/W.,-,;V'•ti-% 12. Estimated Start Date 13.-Estimated Well Depth ft. "Estimated Casing Depth 2—ift. "Primary Casing Diameter � !t in. Open Hole: From '—To ft. 14. Estimated Screen Interval: From 7 5' To9S ft. 15."Primary Casing Material: Black Steel Galvanized PVC Stainless Steel Not Cased Other: 16. Secondary Casing: & -----Telescope Casing =_ CITfor Surface Casing Diameter in. 17. Secondary Casing Material: Black Steel `—galvanized , Stainless Steel Other 18.`Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted Rotary Sonic Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) Horizontal Drilling Plugged by Appro Method Other (Describe) 19. Proposed Grouting Interval for the Primary, S dary, and Additional Casing: From 0 To Seal Material ( Be tonite Neat Cement Other ) From To Seal Material (-/—LTeptonite Neat Cement Other_ ) From To Seal Material n Hite Neat Cement Other ) From TO�Seal Material ( ntonit Neat Cement Other ) 20. Indicate total number of existing wells on site List numberof existing unused wells on site 21.'Is this well or any existing well or waterwith�Jo-l on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) or CUP/WUP Application? Yes f yes,complete the following: CUP/WUP No. District Well ID No. 22. Latitude Longitude 23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84 1 hereby certify [hat I will comply with the applicable rules of Title 40. Florida Adminis[raluo Code. and theta water I certify that I am tho owner M the Properly, that the information provided is accurate, and that I sm aware army use permit or artificial recharge permit, if needed. ties been or will be obtained prior to eommencamenl of wall responsibilities under Chapter 373. Florida Statutes, Io maintain or properly abandon this well; or. I certify that I am construction. I further certify Thal all information provided in this application is accurate and that I will obtain the agent for the o•nm:r. that the information provided is accurate, and that I have informed the owner of t" r necessary approval from other federal. state. or Iotal governments, if applicable. I agree to provide a well respona'bit ilt $ as staD�d bovo owner rmuenls to allowing personnel of this WAfD or Delegated Au;horily access completion capon to the District wilhtn 30 days after completion of the construction, ropa,r, modir—lion. or to the yell .' • during lh conslrucucn. repair, modificelion, or abandonment authonzod by his permit. abandonment authorized by this permit, or the permit expUalion, whichever orcurs first. �.r—Signature or Contractor tense No. u of Ownit r. A44�® !e Approval Granted By Issue Date 7Z17 Expiration Date 2 Fee Received $y Receipt No. Check No. THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES. DEP Form: 62-532.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Date: October 7, 2010 Page 1 of 2