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Home My WebLink AboutWATER WELL PERMITrra Rick Scott Mission: ��s� �� Governor To protect, promote & improve the health of all people in Florida lhf6ugh'integrated Celeste Philip, MD, MPH state, county & community efforts.�� Slate: Surgeon General' and Secretary Vision: To be the Healthiest State in the Nation Florida Department of Health in St.. Lucie County Conditions for Issuance of Water Well Permits Effective July 24, 2017 • Contact the Florida Department of Health in Saint Lucie County (FDOH — St. Lucie) prior to constructing or abandoning any well. a. Call the FDOH — St. Lucie Well Line at 772-873-4936 or email SLCDOH-WELLSaFLHEALTH.GOV b. .Provide the following information: i. Permit number ii. Driller name iii. Address iv. Date and time to begin construction/abandonment • A minimum of 24 hours' notice is required before constructing any public water supply wells. Please call our main office at 772-873-4931 and speak with Environmental .Health Staff or provide notification by email to SLCDOH-WELLS'(a)_FLHEALTH.GOV • Submit revisions to permit and/or site map and associated fee within 48 hours of well construction or abandonment. Florida Department of Health St Lucie County • Division of Disease Control and Health Protection Bureau of Environmental Health 5150 NW Milner Drive Port St. Lucie, FL 34983 PHONE: 772/873-4931 - FAX: 772/595-1306 FloridaHealth.gov mPublid Accredited Health Department Health Accreditation Board File Copy ,5.F l ko zt- 997 . - Pv�'h. L 2 STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, OR ABANDON A WELL .❑Southwest ❑Northwest PLEASE PILL OUT ALL APPLICABLE FIELDS (*Denotes Required Fields Where Applicable) ❑ St. Johns River oUth Florl ❑'Suwannee River The water well contractors responsible fdreomplefing. this form and forwarding the permit application to the appropriate delegated authority where applicable. ❑ D EP Delegated Authority (If Applicable) Unique ID Stipulations Required (See Attached) 152-52h.Quad No. Delineation No. ICUP/WUPApplication CLAYTON DAVIS 540.5 IDEAL HOLDING RD. PORT ST. LUCIE FL 349.B7 407-773-9646 *Owner, Legal Name. If Corporation *Address -City, 'State •ZIP *Telephone.Number 5404 IDEAL HOLDING.RD. PORT ST. LUCIE FL *Well Location -Addre s, Road Name or IS3. oz4O - ) L 0003 - 4 "ParcelIOD No. (PIN) or Alternate 6 eyy *Section or Land Grant *Township 5.BILLY J MCCULLERS JR *Water Well Contractor 6.4072 HWY 441 N. Lot Block Unit 313-15- ST.LUCIE *Range *County Subdivision Check if 62-524: —Yes —No 2707 863-763-2636 JIMMY@SUPERIORWATERWORKS.COM *License Number *Telephone Number E-mail Address OKEECHOBEE , FL 34972 7. *Type of Work: j'_ Construction _Repair _Modification _Abandonment 8. *Number of Proposed Wells 1 *Reason for Repair, Modlfl dlion, or d d r X *Specify Intended Use(s) of Well(s): Domestic Landscape Irrigation _Agricultural Irrigation _Site Investigation _Bottled Water Supply _Recreation Area Irrigation _Livestock _Monitoring _P—Nursery, Irrigation Test DEC 4 2017 Public Water Supply (Limited Use/DOH) Commercial/Industrial Earth -Coupled Geothermal _Public Water Supply (Community or Non _ -Community/DEP) _Golf Course. Irrigation __HVAC Supply _Class I Injection HVAC Return H In S9 Ccui Class V Injection: _Recharge _Commercial/Industrial Disposal. Aquifer Storage and Recovery. _DFainager:HV ONNIENTAL HEALY! Remediation: _Recovery _Air Sparge _Other (Describe) _ official Use Only _Other (Describe) (Note: Not all lypes.of wells are permitted by a given permitting authority) 10.*Distance from Septic System if s200 ft. 75 1 ++ 11. Facility Description DRAINFIELD/SEPTICl2. Estimated Start Date 13.*Estimated Well Depth 10 0 Ift. *Estimated Casing Depth 8 0 1 ft. *Primary Casing Diameter 4 in. Open Hole: From To ft. 14. Estimated Screen Interval: From To ft. 15.*Primary Casing Material: Black Steel Galvanized X PVC Stainless Steel Not Cased Other: 16. Secondary Casing:. Telescope Casing Liner Surface Casing Diameter, in. 17. Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other, 18.*Method of Construction, Repair, or Abandonment: Auger Cable Tool Jetted X Rotary Sonic Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) Horizontal Drilling Plugged by Approved Method Other (Describe) 19. Proposed Grouting,�nterval for the Primary, Secondary, and Additional Casing: From U To Seal Material (__Bentonite Neat Cement X Other cement ) From To Seal Material ( Bentonite Neat Cement Other ) From To Seal Material (_Bentonite Neat Cement Other ) From To Seal Material L_Bentonite Neat Cement_ Other ) 20. Indicate total number of existing wells on site List number of existing unused wells on site 21.*Is this well or any existing well or waterwithdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) or CUP/WUPApplication7 Yes X No If yes, complete the following:. CUPANUP No. District Well ID No. 22. Latitude Longitude 23. Data Obtained From: GPS Map Suivey I hereby canlfy. that I will comply with the applicablo rules of Mile 40, Florida Adminislmfive Code, and that water use permll or otifcial recharge parmil. If needed. has been or will be obtained prier ld commoncamentat Well construction. I further certify that all Information pprovided In this applicallon Is accurate and that I wlil obtain necossary approval from other federal, stale, or to I governments, if uppli6blu. I agree to provide a wall -wmpleton report to Ilia District within 30 days after completion of the construction. repair, modification, or abandonment authorized by this parrot, or the permit expiration, whichever occurs firs]. /i.(IizG�t 1 2707 *Signature of Contractor *License No, Approval Granted Fee Received Receipt No. Issue Date Datum: NAD 27 NAD B3 WGS 84 I.cortKy that I am the ownerof the property. that tno Information provided Is eacurole, and that I aim aware of my •responsibilities under Chapter 373. Flodde Statutes, to maintain or properly abandon this wall; at. I certify that I am the agent for the owner, that the Information provided Is accurate, and that I have Informed the owner of their responsibilities as slated above. Owner consents to allowing personnel of this WMO or Delegated Authority access: to the well site during the consWctlon; repair, modification, or abandonment authorized by this permll ignature of Owner or Agent Expiration Date Check No. 10-24-17 *Date 17 Hydrologist Approval Initials 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. r a Permit No. SOUTHWEST FLORIDA WATER MANAGEMENT DISTRICT 2379 BROAD STREET, BROOKSVILLE, FL 34604-6899 PHONE: (352) 796-7211 or (800) 423-1476 WWW.SWFWMD.STATE.FL.US ST. JOHNS RIVER WATER MANAGEMENT DISTRICT 4049 REID STREET, PALATKA, FL 32178-1429 PHONE: (386) 329-4500 WWW.SJRWMD.COM NORTHWEST FLORIDA WATER MANAGEMENT DISTRICT 152 WATER MANAGEMENT DR,, HAVANA, FL'32333=4712 (U.S, Highway 90, 10 miles west of Tallahassee). PHONE: (850) 539-5999 WWW.NWFWMD:STATE.FL.US Comments: CLAYTON DAVIS 5405 IDEAL HOLDING RD. PORT ST. LUCIE, FL. 34 SOUTH FLORIDA WATER MANAGEMENT DISTRICT P.O. BOX 24680 3301 GUN CLUB ROAD WEST PALM BEACH, FL 33416-4680 PHONE: (561) WWW,SFWMD SUWANNEE R 9225 CR 49 11/16/2017 1 59'PM Sales Receipt #16926 LIVE OAK, FL; Store: 1 St Lucie, County Health IJepartment PHONE: (386) . WWW.MYSUW 5.150 NW Milner Drive Port St Lucie, FL 34983 Environmental Health Division 772-873-4931 Item # City Price EXt.Price --$115.00 68- -- — - - - --1 5115.00T Well Construclia_i_ __ Subfcilal: $115.00 Local Sales Tax 0 % Tax, + $0.00 9 87 RECEIPT TOTAL: $116.00 Credit Card: $115.00 Visa `General Site Map of TBD Idal Holdings "Billy McCullers We Thank You & Have a Good Day! uiaruuiinuplllEll�lllllla Identify known roads and landmarks. Give distances from all reference points or structures, septic systems, sanitary hazards, and contamination sources, if applicable. DEP Form 62-532.900(1) Incorporated In 62-532.400(1), F.A.C. Effective Dale: October 7, 2010 Page 2 of 2