HomeMy WebLinkAboutPERMIT APPLICATIONBy:
tv SCANNED
,� +s7\ie`�I�Stl1�U
�V
p19G _ TOsT St• BY
County
FNRIDA PERMIT APPLICATION To CONSTRUCT,
B6 r OR ABANDON A WELL
-QNorth%19St P} FIr I OUTALb P 1 FIG pS .
1St. Johns River (Denotes RngWrieere "Ppliceblp)
!South FloridaqW
»vrrrrriNrcarurocuuhrtr>uLlcloruumiknny
r'Suwsnnee River rialto mm emwwday rrrrrwmrcdppArrxkn ruax
.:j DE(' Nrw�+ irk•�wrteCGWlhplry,y�vrnyJ.YtnL1Y
•10010 8ted Authonty (if Applicable)
No.
Unique 10 �9
SUPOWbns Required (sec AtW0,d)
0uad No, psl>nedbon M—
UP Appli=twn No.
'Owner Legal Name IF Corporation isles '
Z, 'CitY •SFt1te -ZIP
'v"--acq Ngq��rr Teieptwae Nttmbar
3. L ti i t l T �i ^►
rn, syg, tFIN) or
7. •Type o►work: j�j Canstruc�ion ❑ Repair ❑ MO(firicaWn❑ Abandonment
S. 'Number of Proposer! 4L RS _____�`
Specify Intended Wks) or Weti(q
ja Domestic Landscape 1 ' tf
- _ 61ock `
u ) heck 1162-524 ❑ Yes NO
AiLi
y m E�� dress
city - State I
,N"bW torRepW.
LJ on
eoniecs Water Supply LJ RUM4110n Are& Irrigation �valstook culwqjd IrrlgedOn Site lnvestigadons --
Public Weler Supply (Limped UseoOH) Monitoring
AUGubdc Water Supply (Community or Non-community/0 nursery Irrigation 'rest 17 2�8
Claaa I Injection + Y P) CommerciaUlndustriat Earth-Ccup)ed Geothermal
Golf Course l ' Noit WAC olass V Ir fect(on: ❑ Recharge HVAC Retu ly
Remedielion: ❑ Roomy ❑ Alr� CommerOtherduslrrar samtm;Dispoat ❑Aquifer storage and Recove; (b Dratnsg H M St L� CW
❑ Other Mt#xba} S pa ❑ Other Iwrcnal) E IROI fI
10-.0istance from Septic Systelri if 5 200 tie 11. pd tl
1VEsOmated Wee Depth n, . �r�� rt>yaan_ •12. Esamated Start Date
O�� yImWW Casing Depth X LIL Primary Casirjb Ot }ne in. Open Hole: From
15. Promoted Screen Interval: F rwn O V To l� it S —To h,
15'PclmaryCasinysAat4rrral Gluck Steel t3atvantreG PVC ':
Not Cased }` ttgln 1
18. Secondary Casing: Tries .share 'n
cape Casing Lin
17. Sd=dary Casing Nrstormi er Surface Caslnp Diameter
dlarat Steel Qatvanlzad PVC
is.•Method oiCoStainless Steel r ry r
i>,trucllatl, rtepau, or Abandonment;
Auger Cable Tao! COmbinadnn (7aa or snore Methogs) JottedH flotary l ��,
Horlsartal Drilling ppu and Drivers (Wttl r'01111. Sand Porn. lgya necr All y-
gyed by Approwd m9ihou Other n».sea + e. +^rD o.ea uurty 1 Or the Prirtrary, $acorldery, and a .. Frc To 8061 Mater)al ( 8bntoNte r+rdat Cement other
From To Seal Material ( Sentaphe Ne ant i From To —" Seat Material other _. )
From To ( Bentonse Neat Oamerx Other" y
Seal UatarW ( Sentonite Neat Cement 04her-
20. Indicate total number or existing wells on grip
2 t.'Is tt & well or any exleartg yeti nr water rowel Llsl ntnnber of ex18 N unused wells on silo
or CUPAVVUP ApWlastiorll OWers tort Qua pro Y under a Constral 1
22, L&tltudg Yea �• �b1e �lioer1q pCU NVU!" No. Pt v WQl Use 10 No. (CUPMAJ
IWO--------.� 17tstricl WeA ID No.
23. ate Obtained From:
G✓ S y
u+r uemu a yi+rd�." ,al m• +W "96; L4 r�• Map Survey
Datum: NAD 27 NAD 83 W08 84
e�c.►weon. l"auf■r Nina dlfewW.lr. wen awv ui YawNdD G.L sndnaraa ,rrq.YN,IM�wnaapw
n.tM4lY tEmlmfhw.4rr MnJ.NN.vMOM...�. want r..Wylwf lM�N Wlp.'rr ln.tYy INW++Wtrl irpNEli►.1MfN. dpd lrollla W>rnlo!
�rto� kEM'pWr.d"a^iw.a �+YMNrv+q Mwaro6rh.or WtMlrb.ekatlrW.r.Iw.lrrY,N ,la,
tAhi1170 aiPti<7h1r, f MI! •'seWta.WttaNlirlrfilamwd
N�YanrrlYa try th1! rwe+. era. Inn W
f beau.n `w n1u►�m Ywr•. r ek^.aa r�onnw.r lr YN r,n.r d Mr
r•`• �'", / 'eWMlin°rtelrt4MmNrtwri�irVradW�hp�iri�.on..
din j ro of Contractor C l` E
•ueenre No. 'attlltat+rr� a tamer or--
p.. Grer+lyd by 'aNe
Issue Dais ti>lplrtaepn vats �a��� FeeRecellted ti d"^7'or"lslApp-M
THIS IT: ►$ NOT V,1�iD`�kpra. r- Rl�erpt Cheat No.
PER gtu .`3 t �LL 911 �1 TW FICER OR REPR88ENTATIVE OF THE 1rIMD OR OrMEGATED AUTHORITY. THE
e!*}tVAI LE M 1H :E LL S1 URIMCr I•, R 9 QM, REPAIR. MODIPICATtON.Or2 ASANDONMENTAC'ri6jrte$.
DE
I