HomeMy WebLinkAboutPERMIT APPLICATION FOR NEW WELLSCANNED
BY
LUCIE C.
ST
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2.
STATE OF FLORIDA PERMIT APPLICATION. TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL,i-
❑ Southwest
❑ Northwest THIS FORM MUST BE FILLED OUT COMPLETELY.
❑ St. Johns River The water w=.*contractorlsresponsible for completing this
❑ South Florida form and fcrawding the permit to the appropriate delegated
❑ Suwannee River county e-are eppficable.
'CHECK BOX FOR APPROPRIATE DISTRICT
Name, City and Zip -
Per \a.
Sepb_\o.
Perr Se;
62-=-roil D
wvp i_ piication No.
t
3•
Well Drilli ontractor
ucwsa No.
Tele horetio.
4. '/. of '/. of Section
Address
-
esmanrso p;%eso
(Indicate WeIJ, gn C-�
5. Township`i �r Range
e
City
State Zip
`
C
((na
(Lott
County
Subdivision Name .
Block U
ICheck the use c` welt: % Domestic (Res. Home) _Monitor _irrigation
7. Number of proposed wells
_ Irrigation (Business) Public Water Supply (-S *.:s:ness) List Ot er
Distance from septic system ftistance f a-n foundation
Estimated start of con traction date
Application for: New Construction Repair/Modify
8. App � 1
_Abandonment (Reason for abandonment
9. Estimated:Casirc C_pth Well Depth �bn .Casing hta'= �= BIk-Steel [ Gal/ PVC
Screen interval from t0 Seal Matera: �dk- �
Casing Diameter_
10. If. applicable: Proposed From to Sell
Grouting Interval From to Seal Ma I al
From to Seal %!a-_rial
11. Telescope Casing or liner (check one) D'.a-eter
BIk-Steel / Galvanized / PVC Other (speci ):
12. Method of Construction: Rotary
Cable Tcci Combination
Auger Other (specify):
13. Indicate total No. of wells on site -D—. List No. of t .Lzed wells on site
14. Is this well or any otherweli or water withdrawal on the owners w;:5=nous prop,, covered under
a ConsumptiveM/ater Use Permit (CUPMIUP) or CUPIWUP A:p�n'?� n0 Yes
(If yes, complete the following) CUPIWUP No.
District well ID No. -
Latitude Longitude
Data obtained from GPS _ or map _ or survey ...— (map d_=.=W1 27 — NAD 83 �
Icrt`j=1arnteawredlteproper:y.C•�atdec�-�enpnr�"s bandthatla 3'-37
respenw-cues wider Chap;er 373. Fbdda s,obtas.13 Or.,, abW1dcn dis wek or, I = 7 =_i ar..
the ageetfor Tz owner. dt the intonna5cn proviWr 5 3=xar ar. a: �.e 'rimed e
spers:sdes as steed abere Owner cet sends topercr`d de't:l—z a rr, rese .
J A N 2 0_200or"
15. 1 here.' y ce .jf chat I vn'0 car;ly with the apgr=bte tries of Tide 40, Fledda Adrri.=�i ode.
and yat a wapf use permit a arfa'al recharge permit it needed. has been or will xtce d
pe,or1,aemmer=,,entcrwe]wnstuClen. Ihadrerrxrdy��malhe311 aliGn dl s� s ,is
ap;^,canon a axurate and that will obtain necessary app
ed
appGaabte,l agree tovid provide le compledan repot to the Dis r.Y� days 30
A. lran�6r d eI t fever aacras Arst
AM* -t n�
West �.
�!
IVf, '� 1
t Issue Date: [ HydrciogistApprD•r-]
Approval Granted By: t
Owner Number:
Fee Re �Ved: Receipt No.: Check No.:
Date:
Inspected by: ' EA1 T.
This permit is vas: fcr90 days frc = 62=' cffssu
THIS PERMIT NOT VALID UNTIL PROPERLY SIGNED BY AN AU i r.OL'7cD OFFICER OR REPRESENTATIVE OF THE VAID. rr Si'� 3= AVAILAB.- '—
SITE SURING ALL DRILLING OPERATIONS.