HomeMy WebLinkAboutCONDITIONS FOR ISSUANCES OF WATER WELLr _
l
RECEIVED
Mission:
To protect, promote & li prove the health
of all people in Florida rough inteOAt 2 ® 202
slate, county & commur ly efforts.
ST. Luc1e County, PernI10119
Vision:
NAME)
Ely
ud ftw/
HEALTPJI
be the Healthiest State in the Nation
Rick Scott
Governor
Celeste Philip, MD, MPH
State Surgeon General and Secretary
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
• 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
b. Provide the following in
i. Permit number
ii. Driller name
iii. Address
iv. Date and time to
ation:
in 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(aD-FLHEALTH.GOV
• Submit revisions to permit and/or site map and associated fee within 48 hours of well
nt. construction or abandonme
Florida Department of Health
SL Lucie County • Division of Disease Control and Health Protecti
Bureau of Environmental Health
5150 NW Milner Drive
Port St. Lucie, FL 34983
PHONE: 7721873-4931 - FAX: 772/595-1306
FloridaHealth.gov
I
I
Accredited Health Department
Public Health Accreditation Board
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STATE OF FLORIDA PERMIT APPLI(
REPAIR, MODIFY, OR ABANDON A'
❑Southwest PLEASE Fit
❑Northwest ('Denote;
[]St. Johns River rhewatarwel
❑South Florida thislordtand
[]Suwannee River appropnared
❑ DEP
❑ Delegated Authority (If Applicable)
)N TO CONSTRUCT,
L
f ALL APPLICABLE FIELDS
uired Fields Where Applicable)
webs responsible for comp4ung
ding the penifif opplication ro (lie
,d ourhadly wbeic applicable.
NIS
No. 57— aeo�11�1
Unique ID
Stipulations Required (See Attached)
Quad No. Delineation No. I
UP Application No,
1. Ap alu fef 0A) �f% Li"Ti% .i $zyc, 6'!/7�6/GJUu�I / ✓_4
er, Legal Name if Corporatloq �y —Address n'�I—nrClly Stale ZIP Telephone Number
2 .10 %?9- �.':!�'.r q,4-1/-f:b 1 �l�ldJJ�/J i0 ztG , /- t U� r-� r t� ✓� 02 �27G�
ell Location • ^a'--^^ a^^d ame or Number, City
3.
•Par I ID No. (PIN) or Alternate Key (CircleOhe) t Lot Block Unit,
14. y �, La cz. Check if 62-524:❑ Yes No
• action or Lend Grant 'Towns p, 'R age 'County ,� bdivis'
5. 6 t 7n
ter ell onitaclor •License Number Teleph Numb r E-mail ddress
pe-
a No=
'Water Well Contractor's Address I City Slate 2 P
7. 'Type of Work: 0 Construction ❑ Repair ❑ Modification❑ Abandonment
8. 'Number of Proposed Wells__, I "Reason for RepoV, Mod/fi�wtion orADandormottl
9. 'Specify Intended Use(s) of Weit(s): (� D
Domestic Landscape Irrigation Agricultural Irrigation Site Investigations
Bottled Water Supply [] Recreation Area irrigation Livestock Monitoring
Public Water Supply (Limited Use/DOH) j] Nursery Inigalion ❑ Test
Public Water Supply (Community or Non-CommunityiDEP) Co mmercialllndustdal Earth Coupled Geothermal F E B 2 3 2018
❑ Class I Injection Golf Course Irrigation WAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ CommerclaUindustriai Disposal ❑ Aquifer Storage and Recovery ❑ Drainage0H In St Lude Count
Remediation: ❑ Recovery ❑ Air sparge ❑ Other t i saibo) .I� n
❑ Other (Describe) J
10'Distance from Septic System it 5 200 ft. 11. Facility Description 12. Estimated Start Dale
13.'Estimated Well Depth Mft. 'Estimated Casing Dept / i ft. Primary Casing Diameter in. Open Hole: From To it
14. Estimated Screen Interval: From To '�o fl
15'Primary Casing Material: Black Steel Galvanized PVC Stainless Steel
Not Cased Other.
16. Secondary Casing: Telescope Casing Liner I Surface Casing Diameter in.
17, Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel r
18.•Melhod of Construction, Repair, or Abandonment: i uger Cable Tool Jelled Rota Sonic
Combination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydrau is"Point (Direct Push)
Horizontal Drilling Plugged by Approved McI'thod Other ioescribai
19. Proposed Grouting Interval for the Primary, Secondary, and Additional in :
From To Seal Material ( Bentonite a menl Other )
From To Seal Material ( Bentonite e`at'Cement Other )
From To Seal Material ( Bentonite Neal Cement Other )
From To Seal Material ( Bentonite Neal Cement Other )
20. Indicate total number of existing wells on site I List number of existing unused wells on site
21.•Is this well or any existing well or water wit raw Hop the owner's contiguous proper�tyy covered under a Consumplive/Water Use Permit (CUP/WUP)
or CUPNVIIP Applicafion'T Yes No If es. complete the following: CNWUP No. District Well ID No.
22. Latitude i u
23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
I herar0y aH
eby y Bul l a7 catplv the apprwblo rtdos of Tito 40, 4v.6ve code, and Owl. warn I weN Owl I un the morel at the plop . ewt the inlamatiat pfo✓d6d6 acetaate, VoleW I an t we cf my
uu pemAlarfiedel recharpo Dernf.11noedea has bocn or w7 the obbA.d pdd r. mraneneemenlof wee 1=pwrsJMafuntlnth&pkt]77, FlodefMahttp.m troMhhvupmpady abNdan Ova we; a,IceNNlhatlan
conaoucson.IM.Iha ntdry tlW u7 tnhrtrmem PmNtlaJln this appicnAon b.ccwou and lh.11wa Oalse Inct''
ate ovma.OWl 1nfofnudonPlwtdddleeauratenewaary vpptwaf poor Derr rednd. al.le. or brat Dwernttwnb, tf epprr 3 A& I efp.e fl that ldm a Mar rnn ne mud . o. mnamn to e7aMn9 Deraartel of qis WAD aadepateO kdualry aeaeasPe Dbbkt rAwn 70 oeye.5.1 .1ze.on of Ow canoe.dion, repaa•rtadtcne.n.a to mj%con .ropait, modAotlur. or abendaunentauYtalaadby Wf pnmit
alud by Ode pami of Ne pntril eapLMion, wAthNef occurs Ncl. Al
eQqyl
'License No.}On re of wrier ar Agent 'Dole
Approval Granled By i Issuo Date_ Expiration Date O 1 �iSf1nGah
Fee Received 5HyarologrstApprovol
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: 62-532.9000) Ineorpomied in 62-532.400(1), F.A.C. �Effectivo Date: October7, 2010 PaOo 1 1
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