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HomeMy WebLinkAboutOSTDS New 10-20-17STATE OF FLORIDA DEPARTMENT OF HEALTH 1 ONSITE SEWAGE TREATMENT AND DISPO SYSTEM RV. T`7 f (' 0 0 �'?3 PERMIT #:66-SF-1801434 APPLICATION #:AP1314571 •_ D: PA`, NOV 2 0 2017REc PT PR1082791 CONSTRUCTION PERMIT FOR: OSTDS New APPLICANT: Brad & Nicole Beddome PROPERTY ADDRESS: TBD Dyer Rd Fort Pierce, FL 34982 LOT: BLOCK: 2 SUBDIVISION: St. Lucie Gardens [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 3414-501-1409-350-0 [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 [ 1,050 ] GALLONS / GPD Sentic 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 [ ] D [ 667 ] SQUARE FEET Drainfield new SYSTEM R [ ] SQUARE FEET N/A SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [XI MOUND [ ] I CONFIGURATION: [ ] TRENCH [XI BED [ ] N F LOCATION OF BENCHMARK: yellow capped BM iron rod E side of Dyer rd I ELEVATION OF PROPOSED SYSTEM SITE [ 4.00 ][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 12.00][ INCHES FT ][ABOVE BELOW] BENCHMARK/REFERENCE POINT L D 0 T H E R FILL REQUIRED: [:i4.UU] INCHES EXCAVATION REQUIRED: [ ] INCHES The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of 400 gpd. The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s. 64E-6.013(3)(f), FAC. SPECIFICATIONS BY: Brian J Ingr TITLE: Environmental Specialist II APPROVED BY: a TITLE: Environmental Specialist II St. Lucie CHD Brian J Ingra DATE ISSUED: 11/17/2017 EXPIRATION DATE: 05/17/2019 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC v .1.1.4 AP1314571 SE1054008 �'Al-C Copy Page 1 of 3 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 r 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. St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 'HEALTH ;PAYING ON: PERMIT #: 56-SF-1801434 BILL DOC#:56-BID-3624833 CONSTRUCTION APPLICATION#: AP1314571 RECEIVED FROM: KARNERINC AMOUNT PAID: $ 515.00 PAYMENT FORM: CHECK 1578 PAYMENT DATE: 11/08/2017 MAIL TO: Brad & Nicole Beddome FACILITY NAME: PROPERTY LOCATION: TBD Dyer Rd Fort Pierce, FL 349K 2 Lot: Block: _ Property ID: 3414-501-1409-350-0 EXPLANATION or DESCRIPTION: 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 1 1 1 1 1 1 1 QUANTITY FFF 5.00 15.00 100.00 100.00 115.00 55.00 75.00 50.00 RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-3433384 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEXAGE TREATkMNT AND DISPOSAL SYSTEM a "m APPLICATION FOR CONSTRUCTION PENT APPLICATION FOR: [� ] New System [ ] Repair wZ4 5S'ZeaV.- PERMIT NO.5Ae - NV DATE PAID: FEE PAID: RECEIPT #: CV, [ ] Existing System [ ] Holding Tank [ ] Innovative [ ] Abandonment [ ] Temporary [ ] APPLICANT: Bradley R & Nicole D. Eeddome_ 1i2-93"7S000 AGENT: Karner Surveying Inc/ Mr. & Mrs Beddome TELEPHONE(772) 288 7206 MAILING ADDRESS: 2740 SORT Martin Downs B1vdf333, Palm City Fl. 34990 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: S165' of N 495' Less E330' L9 BLOCK: 2 SUBDIVISION: St Lucie GardensPLATTED: 1910 PROPERTY ID #: 3414-501-1409-350-0 ZONING: I/M OR EQUIVALENT: [ Y / N ] PROPERTY SIZE: 1.25 ACRES WATER SUPPLY: PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / N ] PROPERTY ADDRESS: Dyer Rd, tort Pierce, Fl. 34982 DIRECTIONS TO PROPERTY: SEE ATTACHED BUILDING INFORMATION Unit Type of No Establishment 1 DISTANCE TO SEWER: FT [ d] RESIDENTIAL [ ] COMMERCIAL No. of Building Commercial/Institutional System Design Bedrooms Area Spit Table 1, Chapter 64E-6, FAC RESIDENCE 3 2610 2 3 4 [ ] Floor/Equipment Drains [ ] Other SIGNATURE: DATE: 9-30-17 DH 4015, 10/97 (Previous Editions May Be Ts d) ONLINE VERSION Page 1 of 4 APPLICANT: Property owner's full name. STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATION APPLICANT: Brad & Nicole Beddome CONTRACTOR / AGENT: KARNERINC LOT: BLOCK: 2 APPLICATION # AP1314571 PERMIT # 56-SF-1801434 DOCUMENT # SE1054008 SUBDIVISION: St. Lucie Gardens ID#: 3414-501-1409-350-0 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: 1.25 ACRES TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES-TABLEI / OTHER -TABLE 2 ] AUTHORIZED SEWAGE FLOW: 1875.00 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: 1600.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT BENCHMARK/REFERENCE POINT LOCATION: yellow capped BM iron rod E side of Dyer rd ELEVATION OF PROPOSED SYSTEM SITE 4.00 [ 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: 15 FT NORMALLY WET: [ ]YES [X]NO WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 100 FT NON -POTABLE: FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 75 FT SITE SUBJECT TO FREQUENT FLOODING? 10 YEAR FLOOD ELEVATION FOR SITE: Ql1TT. nWMVTT-r T1 Wn12b2TT(-W CTTF. 1 [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO] FT [ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD SOIL PROFILE INFORMATION SITE 2 USDA SOIL SERIES:Waveland fine sand Munsell #/Color Texture Depth 10YR 4/2 Sand 0 To 3 10YR 4/1 Sand 3 To 15 10YR 5/1 Sand 7 To 29 10YR 2/1 Spodic Material 29 To 34 HOLE CAVING Refusal 34 To 72 USDA SOIL SERIES:Waveland fine sand Munsell #/Color Texture Depth 10YR 3/1 Sand 0 To 4 10YR 4/1 Sand 4 To 17 10YR 5/1 Sand 8 To 31 1 OYR 2/1 Spodic Material 31 To 36 HOLE CAVING Refusal 36 To 72 OBSERVED WATER TABLE: 4.00 INCHES [ ABOVE / BEE] EXISTING GRADE TYPE: [ PERCHED / APPARENT ] ESTIMATED WET SEASON WATER TABLE ELEVATION: 8 INCHES [ ABOVE / BELOW ] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X]YES [ ]NO DEPTH: 8.00 INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [XI BED - REMARKS/ADDITIONAL CRITERIA Sand/0.60 DEPTH OF EXCAVATION: INCHES [ ] OTHER (SPECIFY) WSWT determined using USDA WSS and soil borings. 10yr5/1 stripping In 10yr411 matrix >10% with diffuse boundaries starting 8" In S61. SB1 4" below BM. S62 2" below BM. A SITE EVALUATED BY: Ingram, Brian (Title: EpVlronmental Specialist ll) (ENVIRONMENTAL HEALTH) DH 4015, 08109 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC DATE: 11/15/2017 Page 3 of 4 AP1314571 EID1801434 v 1.0.2 n STATE OF FLORIDA PERMIT DEPARTbMET OF HEALTH ONSITE SEWAGE TREAWENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS APPLICANT: Bradley R 6, Nicole D. Badd®me AGENT: KARNER SURVEYING INC/M/M Beddome LOT: S165' of N 495' Less E330' L9 BLOCK: 2 SUBDIVISION: St Lucie Gardens PROPERTY ID #:3414-501-1409-350-0 [Section/Township/Parcel No. or Tax ID Number] TO BE COMPLETED BY ENGINEER, HEALTH DEPARTEMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINNEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: TOTAL ESTIMATED SEWAGE FLOW: 400 AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: 1600 [-l] YES [ ] NO NET USABLE AREA AVAILABLE:0.98 ACRES GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE23 GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE] SOFT UNOBSTRUCTED AREA REQUIRED:1000.5 SOFT 3ENCHMARK/REFERENCE POINT LOCATION: Set SRC near East E/P Dyer Rd.El.15.21 NAVD PLEVATION OF PROPOSED SYSTEM SITE IS 0.89 [INCHES/Ft] [ABOVE/BELOW] BE POINT ['HE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: 75' FT DITCHES/SWALES: 15' FT NORMALLY WET? { ] YES [ ] NO SELLS: PUBLIC:N/A FT LIMITED USE: FT PRIVATE: 75+ FT NON -POTABLE: 50 FT 3UILDING FOUNDATIONS: 5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 10 FT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [1] NO .0 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SOIL PROFILE IN MUNSELL #/COLOR USDA SOIL SERIES: TION SITE 1 TEXTURE DEPTH TO TO TO TO TO TO TO TO TO 10 YEAR FLOODING? [ ] YES [J] NO SITE ELEVATION: FT MSL/NGVD SOIL PROFILE INFORMATION SITE 2 MUNSELL #/COLOR TEXTURE DEPTH TO TO TO TO TO TO TO TO TO USDA SOIL SERIES: BSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE:[PERCHED / APPARENT] STIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ABOVE / BELOW] EXISTING GRADE IGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES OIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: RAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY) &MARKS/ADDITIONAL CRITERIA: CTE EVALUATED BY: 4015, 10/96 (Replaces HR3-9 Form 46].5/[page 31 which may be used) DATE:9.30.2017 INCHES Page 3 of 4 3TRUCTIONS: )roperty Card Page 1 of '. Michelle Franklin, CFA -- Saint Lucie County Property Appraiser -- All rights reserved. Property Identification Site Address: Dyer RD Parcel ID: 3414-501-1409- Account #: 41183 Sec/Town/Range: 350-0 25/36S/40E Map ID: 34/25N Zoning: RM-5 Use Type: 0000 Jurisdiction: Saint Lucie County Ownership Legal Description Bradley R Beddome ST LUCIE GARDENS 25 36 40 BLK 2 S 165 FT OF N 495 FT Nicole D Beddome OF LOT 9-LESS E 330 FT- (1.37 AC) (MAP 34/25N) (OR 731 SW Great Exuma CV 4030-1002) Port St Lucie, FL 34986-3450 Current Values Historical Values 3-year Just/Market: $26,200 Assessed: $25,156 Year Just/Market Assessed Exemptions Taxable Exemptions: $0 Taxable: $25,156 2017 $26,200 $25,156 $0 $25,156 2016 $28,300 $22,869 $0 $22,869 2015 $24,300 $20,790 $0 $20,790 Date 08-04-2017 01-04-2004 09-27-2002 View: Year Built: N/A Primary Wall: Bedrooms: 0 Full Baths: 0 Half Baths: 0 Sale History Book/Page Sale Code Deed Grantor 4030 / 1002 0001 WD Flaherty Gregory J 1895 / 0426 XX00 WD Stephens,Dwayne 1604 / 1877 XX02 WD Jacob Aaron Corporation, 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 $40,500 $60,300 $36,000 Building Type: Effective Year: 2014 Secondary Wall: Primary Int Wall: Avg Hgt/Floor: 0 Primary Floors: Total Areas Finished/Under Air 0 (SF): Gross Area (SF): 0 Land Size (acres): 1.39 Land Size (SF): 60,548.4 Total Building Count: 1 Special Features and Yard Items Qty Units Year Blt 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. ttp://www.pasic.org/RECard/ 11/8/2017 oogle Maps 3855 Old US Highway 1, Fort Pierce, FL to 245-5-Dyer Drive 12.0 miles, 28 min Road, Port St. Lucie, FL II,Ier:,ill lnr,.,I Fi;r'•rnt `' 11.: tYtvvv.UJ7;SFL_,: o,.r,f hr ,OYs iUR, r• Ft,Prerce /Wet, . . a„� .'State Park; 3855 Old US Highway .1.Q .,. `f --� 35 min Fort ierce 14.2 miles .;.i �IlitlJr•: ftl': !'(� is - „ - Stole f'0Ijvgf,b i;, 28 min "0 nulrs f1 ` Ine 32 min .I 13,3 miles - • - , \; ^, Indian River. ;�Taj , � t xtah•:^ I _ f r'• (J2355 D'yeK.Road Jens n.Rr�crr R,ver Fark tQ :Jupiter n �'ooglre , Savannas fF?re5c,r,c. �CiA V,i1a e `✓crane � - . Koster t lornes Preserve State Pare.:' Map data ©2017 Google United States 2 mi via US-1 S 28 min Fastest route, the usual traffic 12.0 miles a'��S This 10W(2 '1`10, 0r I rivatt`. i C,;1ta via Sunrise Blvd and US-1 S 32 min 13.3 miles via FL-615 S/N 25th St and US-1 S 35 min 14.2 miles STATI REPA PE �Ao C]Sout D Nortl x ❑ St. J d' I_) Sout Suwi Ob ❑ DEP _-. Dele, 'Owner, Legal Name 2. 'Well Location -Address, • 3. ' y,�-s70I—sot_ "Parcel ID No. (PIN) nr AI 4. C—> 'Section or Land Grant 5. >0R Barre A- - 'Water Well Contractor 6. P,D, s60, 5S4 'Water Well Contractor's Apt 7. 'Type of Work: 7onstr B. 'Number of Proposed Wells 9. `Specify Intended Use(s) of _mod Water Supply _ Public Water Supply (Limite Public Water Supply (Coma _Class I Injection Class V Injection: _Recharge Remediation: _Recovery Other (Describe) 10.'Distance from Septic System 13.'Estimated Well Depth 14. Estimated Screen Interval: Frc 15.'Primary Casing Material: 16. Secondary Casing: Tell 17. Secondary Casing Material: • 18.'Method of Construction, Repa Combination (Two or A Horizontal Drilling _ 19. Proposed Grouting Interval for From To Seal From —To --Seal From To Seal From To Seal 20. Indicate total number of existing 21.'Is this well or any existing well I or CUP/WUP Application? _ 22. Latitude 23. Data Obtained From: GP Pam* c8llri Nat l Wrfi cdmpiy..ilh Lha appliabia rJll use pprmil or er0=1 ro:horse pe.•naL if needed, has t :onsUu:liar. ! rurlho::etiry hat ai: irfdr..,oliar. provide ,"as52ry app.•dvai from 01he: fedora!, stale, or local Si a�piccdn ra-non to Ihp District a•:Ihi- 30 days and., cot eta-dpnmenl au1F - 4 by tics oall.-I. or 11%e do.=it e, OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, 5'�O-rS/' - ) go ) sy Z, MODIFY, OR ABANDON A WELL Permit No vi-Cj ^�7-1o011 ins River Florida inee River, PLEASE FILL OUT ALL APPLICABLE FIELDS Florida Unique ID (`Denotes P.equired Fields Where Applicable) Permit Stipulations Required (See Attached) The walar well coniraclor is responsible for complaling this fora, and forwarding the permit application, to the 62-524 Quad No. Delineation Ns. appropriate de.aegatad euthorify where 3cplfrable Authority (If Applicable) .1,/o vr^G R,A 'Address _ } sr' uf� or Number, City • 3 S o -- U go 5� 6106 'Range I `'Cr�7Lou^nty l LV S it 1 O 'License Number •TPIF CUP/WUP Application 'State 'ZIP •Telephone Number Lot Block Unit Subdivision Check if 62-524: — Yes _ No -a►S"-��S(oot NPVbr',1�?r1a(�:,qrnca;l ccrh ,hone Number E-mail Address State ZIP 1_Repair _Moditication ,Abandonment for Repair, Modification. or Stamp !' Landscape Irrigation _Agricultural Irrigation Site Investigation ® � m _Recreation Area Irrigation _Livestock 'MonitoringD D D (`f Use/DOH) — Nursery Irrigation Test inity or Non-Comunit /DEP Commercial/Industrial _ Earth -Coupled Geothermal y )_Golf Course Irrigation HVAC Supply _`HVAC Return NOY 1 7 _Commercial,lndustrial Disposal __Aquifer Storage and Recovery __Drainage Air Sparge _Other toescnne) ui C Vrl _(Mom. Nn: of types 3'V.-OS are Defrnifleo by a g!•.•e^ per niC:rg au;Fos:y) 5200 ft. 75 11. Facility Description NNMENTAL HI 12. Estimated IV Dare L 'Estimated Casing Depth / o ft. 'Primary Casing Diameter Z in. Open Hole: From To n To ft. —Black Steel `_Galvanized _Lc' PVC Stainless Steel _Not Cased Other: scope Casing Liner Surface Casing Diameter in. __Black Steel _____Galvanized PVC Stainless Steel _Other _ or Abandonment: Auger Cable Tool Jetted (>4 Rotary _ onic )re Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) —Plugged by Approved Method __Other pe3zribei. he Primary, Secondary, and Additional Casing: Material _Bentonite Neal Cement Other_ _) Material (Bentonite Neat Cement Other ) Aaterial (_ Bentonite Neat Cement Other ) Aaterial (^_Bentonite Neat Cement Other ) wells on site List number of existing unused wells on site g • water• withdrawal on the owner's contiguous property covered under a Consumptive/Water Us� Permit (CUPIWUP) _Yes 01 No If yes, complete the following: CUP/WUP No.—, District Well ID No. Longitude ` Map Survey Datum: NAD 27 NAD 83 WAS 84 of , :I b Flenda Admrnsl7l've code, and that a water • certify hat l am t.e :caner of the order-i. I681:Se mic? lalior wcti'.e:'s accurate. and 1-a!' a- "aid , - m or vE!I be obtained anon Id :omr..er.;prerl res;orsiblues ardor c`a;lor 373, R-da Statplas, m •rairta!r. a• I t ;f ^Y in Ir.:s ap: i:aL':r rs a::°ra!a a L-.al :,v!I' c:la: pra;eriy ptanconra•a- Mrenls, if =ii:aa:a i agree 1: pronde o :..:I tea agent fp• the Shea lha! l e. mfm-at•or erov ded is`Tp• a ,cr:-oilra :.�-en,.-c.• wilco- of Me :o,s:rJ-Vcr, re;a'r, n+ 6;a1'c-, r '°s:onsibii{•es as slats: ab:ve. rill-ef =SVIe !c a!i 1.':ng:es:rsei :f ttir2 l; r,1D :• Drto3elol �uec+;' a:ca;; ,mlidr, vih_-ave'::ou•s fast Ile well s!le 7.r,n; JMe :arsl:rbcr.'e:a.• n,:diF:at•dr„ =: aeandc .-er: 3le.-•c1+Let Ill r� l�C.ntractdr I � O � � � i 'sign re o— 11/08/2017 'License No. 'Signature of Owner or Agent 'Date Approval Granted By _/ —_ Issue Date 17 . ? / Expiration Fee Received 5 Raceipl No Date 5 l 7 % Hydrologist Approval ! l i _ . — Check No. THIS PERMIT IS NOT VALID UhiTIL PR PERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WrAD OR DELEGATED AUTHOR] . Y% THE oERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION. REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES. )EP Form: 52-532.900(1) Incorporated n 62-532.400(1). F.A.C. Effective Date: October 7,2010