HomeMy WebLinkAboutAPPLICATION TO CONSTRUCT WELLr
Mission:
To protect, promote 8 improve the health
of all people in Florida through integrated
state, county 8 community efforts.
i
WANNED
- 13Y
9 1
ggIiEALT11 l i.gy:g.
Vision: To 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
Effective July 2 t, 2017
. I
• 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
SLCD0H-WELLS0.FLHEALTH.G0VI
b. Provide the following information: I
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 I
St Lucie County • Division or Disease Control and Health Protection
Bureau of Environmental Health
5150 NW Milner Drive Accredited Health Department
Port St. Lucie, FL 34983 + : Public Health Accreditation Board
PHONE: 772/873-4931 - FAX: 772/695-1306
FloridaHealth.gov
FILE COPY
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, r ^ A/�
REPAIR, MODIFY, OR ABANDON A WELL Penntt No._ i r �C�I
0Southwest PLEASE FILL OUT ALLAPPLICABLEFIELDS Florida Unique ID
t.'.,Northwest '('Denotes Required Fields Where Applicable) Perind Stipulations Required (See Attached)
❑SL Johns River '
MSouth Florida inewaterweircontraCcrisr sponsibtef)rmmplefing
S4 tfrfs form and fonvar lhg tiro pennr application, to ft 62-524 Quad No. Delineation No.
uwannee River appropriate deregated autborfty,vhere apprrrabte.
`- 0 OEP I CUPANUPAppllcation No.
❑ Delegated Authority (If Applicable) -
mM s
1. e o N LO e Catig Pov+ Sit- .lal.cze R- ice% 50 -19 if�aQ.20
ICD'mer, Legal Name if Corpora on *Address 'C' *State 'ZIP 'Telephone Number
Location -Address. Road Name or ' bei. City -
3. G+'ZZL(o/-0(93c--0UU-Z 3
"Paces ID No. r(PIN) or Alternate Key (Circle One) L j j /� of /_ Block Unit
4. -Z 7 3 3 e �7 �VC� t' I ��� ` f Uir- (- d (i -) /'rr `--r0 /.� Check if 62-524: Yes _ No
xS^ ion or Land Grant' •Township 'Ra ge 'County _I Subdivision / — /
5. _A it G ,^ rc 1-F )) O Z S -7 i Z Z f S S' 8 6 5
•V1�r Wei Contractor 'License Number 'Telephone Number E-mail Address-/
s. PLC oT 4) (,1 f 1- f4c y 1 5-Y
'Vkler Well Contractor's Address city State ZIP
7. '?)ye of Work:r Construction ,Repair `Modification _Abandonment
B. -Nmbar of Proposed Wells I 'Reason for Repair. A7oditkalon. or Abe
9. pecify Intended Uses) of Well(s): I � t
Domestic Landscape Irrigation —Agricultural Irrigation Site Investigation
Bottled Water Supply _Recreation Area Irrigation —Livestock _Monitoring
Public Water Supply (Limited Use/DOH) —Nursery Irrigation Test Commercial/Industrial —Earth-Coupled Geothermal MAY I
A� ` AOq I�
Public Water Supply (Community or Non-Community/DEP) —Golf Course Irrigation _HVAC Supply
Gass I Injection l _HVAC Return
Clas$V Injection: _Recharge _Commercial/Industrial Disposal I Aquifer Storage and Recovery _Drainage kIPOINUMYAJ
OH In St �� C_�
Rennediation: _Recovery —Air Sparge _Other (Desuibe) I W
('/lher (Describe) (Note: Not all types of welts we permitted by a given peanit n9 authority) a
10.'Datance from Septic System if S200 ft. _74Lz 11. Facility Description 5 12. Estimated Start Date .
13.'Estimated Well Depth �4) ft. 'Estimated Casing Depth S 1} ft.i 'Primary Casina Diameter Z in. Open Hole: From To ft.
14. Estimated Screen Interval: From To ft.
15."Primary Casing Material: Black Steel Galvanized PVC Stainless Steel
NotCased Other:
16. Secondary Casing: Telescope Casing Llner SuHace Casing Diameter in.
17- Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
1B.'Method of Construction, Repair, or Abandonment: --Auger Cable Tool Jetted •�(Botary Sonic
`Combination (Two or More Methods) Nnd Driven (Well Point. Sand Point) Hydraulic Point (Direct Push)
"Horizontal Drilling Plugged by Approved Method l Other (oea✓ibe)
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
From To Seat' Material L_Bentonite NeatlCement Other )
From To Seal Material (_Bentonite Neat Cement Other
m )
FroTo Seal Material �_Bentonite Neat Cement Other )
From To Seal Material �_Bentonite Neat'Cemenl_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 water withdrawal on the owner's contiguous property covered undera ConsumptivefWater Use Permit (CUP/WUP)
or CUPNVUP Application? Yes >:�'No If yes. complete the following: CUP/WUP No. District Well ID No.
22. Latitude Lon_aitude
23. Data Obtained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84
1 nersby tatney p-at 1 wm wan ftappambm ruses Of Me 40. FcltCa Ad. mroOrn Lode, anw d'at a ale. i .On„j• P.al r an th0 w-.e or the piopary. 1ha1 LNO WO aubn MoAded a arrtrab. 2-M ftt an ante -1 ry
use permit cr aNtial:xhaige pomd. needed, has bs:n or A tt obrainrJ pncr b'J' nme:!tO.T.ent or was msporsitdees unda ba er 373. Farida Statutes. to c+amyin or pmpery abandon thrs coo!_': or, t cendy as I a:.
r shxtloa 1 further Lediry Nat all irf n oron Veiled in prig eppp:mrvn is aOC o10 me Ihal I wen cb.1h :a avertW a," onr, :. N• Re :rdraiLbet prOvAld'S aa'1•'dle, and Ihal I Fave 71(Omled IEa pwT.er or eeh
nsctseay sppov l ha. error fOdereL 0 days are. *U000f OeacpGmela l ogics rop:o.^de r:wo: retparsro:K, as c4 a �'. Ovoerorntenb to n7owry pers9nnel of rt$ VMo6 0e'�alart Auttony aC.ess
ainUeson report b the UWAcr wptih b days aLar SmpfeCCn Of Q+e tansVucSw-., repe4. O!trr00.. or b e`-O •.eq shn duchy ..0 rSl1=40n. rtlpaif. nbdd eou' l Or abalkonr. t auff nztd by P.g pema
aaaidoetnrrt eutfxez d by this pemiL or me perlmt eaarn[on. -N&.a f Occva Alat.
'Signature of Canfra 'License No. Sigma nature of Ow o 'Dalo
.• OFFICIAL USS
Approval Granted By Issue Dat �/'
I �_ Expi on Date b I Hydrologist Approval
mwaa
Fee Received 5 Receipt No. _ Cherie No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BYAN AUTHOR14ED OFFICER OR REPRESENTATIVE OFTHE WMD OR DELEGATED AUTHORITY. THE
PERM IT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES.
0EP !%rm: 62-532.900(11 Income, ora!ed in 62-532.40e(/ ). °A E9ea!•re rJ, ate: O� dt>°.r?. 20?0 Para 1 of 2
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FND PK
99 20 N 89 ° 27' 39"E g9 a9 W A L D 0 PEPPER DRIVE
PROJECT BENCHMARK } ASPHALT 325.00' 9g10 (60' I.E.E.)
FND PK \ NAIL (NO ID) f EL=100.00 (ASSUMED) f
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99. 97
— -- -- ----- --- 10' U.E. I
132.5'
PROPOSED
12' X 51 '
SEPTIC SYSTEM I I I I I
IIIII
t�� IIIII
IIIIIgB.�
IIIII
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132.5' --- t
1.3'
-�Tft 7
W
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iv 8.2
ono
COVERED
N ENTRY \
"-[,
� 132.5'
10.1' 13.5
3.0' 7.8' 1 0'
0.9' 1.9'
LOT 35
PROPOSED
RESIDENCE v?
PROPOSED
FFE14.2D
1'42.6'
PROPOSED
o COVERED WELL
2 7.0' 0 2.6'
LANAI cv
-t------- - 7. 132.5'
I 2.4'
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