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HomeMy WebLinkAboutDEPT OF HEALTH ISSURANCE OF WATER WELL PERMITSv Florida SL Lucie Bureau 515010 Port St. L PHONE: oted promote & improve the health people in Florida thro in egiratKECEIVED " G ls:: �;„ c "', county & community Sorts. NFAI TPA A U G 2 3 2018 Vision: ro be the Healthiest State in the Nation ST. Lucie Rick Scott -Govemor Celeste Philips MDR MPH State Surgeon General and Secretary Florida Department of Health in St. Lucie County 'Conditions for Issuance of Water Well Permits SCANNED Effective July 24, 2017 BY St. Lucie Gou 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-WELLS(cr,FLHEALTH 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 requiredbefore 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-WELLSIa.FLHEALTH.GOV Submit revisions to permit and/or site map and associated fee within 48 hours of well construction or abandonment:' apartment of Health ounty • Divlslon or Disease Control and Health Protection Environmental Health e,�FL34983 Accredited Health Department '2/873-4931 - FAX: 772/595-1306 Public Health Accreditation Board Ith.gov FILE'C OPY STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, OR ABANDON A WELL Permit No. x �W ❑Southwest PLEASE FILL OUT ALL APPLICABLE FIELDS Florida Unique ID l7 Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required (See Attached) 0St. Johns River ❑South Florida The water Ivell contractor is responsible for completing This form end tonvarding the permir application to the 62-524 Quad No. Delineation No. D Suwannee River appropriate delegated authority where oppricable. 0 DEP CUP/WUP Application No. ❑ Delegated Authority (If Applicable) ONLY- `Oqvner. Legal Name if orpora o 'Address 'City 'State ZIP 'Telephone Number 2. g701 &goLC iav%at. 1Jr; R i,emxl ri 3�fri82 __ W �I Location - Address, Road Name or Number, City — .P .--GC1 �I22-- �---------------- ---------- Fel ID No. (PIN) or Alternate Key (Circle One) Lot Block Unit 4. 'I o'Z ?Ms 1' G . l 'Se6'tion or Land Grant 'Townsh•p 'Ranee 'County Subdivision Check if 62-524: _ Yes _ No CAI.-'�90�_ s�ev;� .;ate � ����n.�c�� '1Na er Well Contract r 'License Number 'Telephone Number E-mail Address 6. 'Wa er Well Contractor's Address City State ZIP 7. 'Typ�l of Work: — Construction _Repair _Modification _Abandonment TIber of Proposed Wells Reason for Repair. Modification. or Abandonment 8. 'Nu 9-'Specify Intended Use(s) of Well(s): —Domestic ✓Landscape Irrigation _Agricultural Irrigation Site Investigation Bottled Water Supply _Recreation Area Irrigation _Livestock —Monitoring Nursery Irrigation Test Pu tic Water Supply (Limited Use/DOH) — J —Golf _Earth -Coupled Geothermal A f t Public Water Supply (Community or Non-Community/DEP) _Golf Course Irrigation HVAC Supply AUG 2018 __ CI �IsIs I Injection _—HVAC Return Class Vtnjection: —Recharge —Commercial/Industrial Disposal —Aquifer Storage and Recovery _Drainage H in St Lucie Coo O Remedi ion: —Recovery —Air Sparge _Other (oescribe)MAL _OlhllIe�lI r (Describe) (Note: Not all' pes of iveils are permitted by a given permitting authority) I 10. Dislalice from Septic System if t200 R.d 11. Facility Description S'c`� ��y��� .���j 12. Estimated Start Dale 13.'Estin1Illl led Well Depth L30ft. `Estimated Casing Depth I f 0 ft. 'Primary Casing Diameter in. Open Hole: From To ft. 14. Estimated Screen Interval. From I 10 To i Ofl. 15.-Pdmal I Casing Material: Black Steel Galvanized 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.-lvlelhog or Construction, Repair, or Abandonment: Auger Cable Tool Jetted Rotary ___—Sonic Combination (Two or More Methods). Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) _ orizontal Drilling Plugged by Approved Method Other (Describe) 19. Propos d Grouting Interval for the Primary, Secondary, and Additional Casing: From �O To r 10 Seal Material ( Bentonite ✓ Neat Cement Other ) From lil To Seal Material ( Bentonile Neat CernenlF Other ) From—'1 To —Seal Material( Bentonite Neat Cement_ Other ^_) From To Seal Material ( Bentonile Neat Cement --Other ) 20. Indic Iltotal number of existing wells on site List number of existing unused wells on site 21.•Is this,,fL1l or any existing well or water withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) or CUP YWUP Application? Yes _ _No If yes, complete the following: CUP/WUP No. — District Well ID No.- 22. Latitud�; Longitude 23. Data ObJJained From: GPS Map Survey Datum: NAD 27 NAD 83 WGS 84 I hue_�y cerbfy tnolt� 1-vJl comply imm fee appLG]blo rote`. of Llle a0. rmdda AdnurlisVa W¢ CWC, and Uw: a natal 1 eerily that f am rho mm of the property. that the infunrabon provided is accurate, ai;d 0,011 mn .hare W my usd pnrm:rMarbeR]Ir•1tiLVge pOrtni4d needed,hacbaan pr:na be ftLinn P,a loce—G.M.0.1 of: 11 ttnpnn:iCi4un5 under Chapror 37a, Florida Statutes. tonmmiain or prnpnny.lhandpn ln,S t�P,:l; pr,lr.(:ni(y pilll lm u-n57m Lien. I lurocerbry that off lNofma:On provided W Un lu applicatios ac vrato and that I %W.i Cowin thu anent fro via ginner, that the infoimalwn Ororhled is aco,raln, and that I havo mfenned Urn —nor of t their necrsary api rr. t -;liar We". 51310. or Intl govnmmmrs, i; applimbld. f agme to par,nde a.ra�l rC wnsrniibns as staiad above. a -mar consent^ to anib%ing personnel of this %%.n.in at ❑niagatn0 AulhOnty arttlM Ccrnefetion rely. District oilain 3D days afar COmplebOn of the COnSt-60n. repair, inpd,kat— cr to Ino —Il sttn gom ring iha consWcdan, foppir. ad6oalion. Or tam Whonaad by Nis po—d. ahnnuwn�rin:ha : b by Ut�c perm. nr mo pOrmit c+fvavrm, ;vauumvnr ctous rr,.t, it 5i n e of ontractor 'License No. 3 ignatu wne gent 'Date (� Approval Gran i d By /rJ A —_ — Issue Date J�J Expiration Date 2 f Hydrologist Approval IfubaL- Fee Received 5 Receipt No. ___ Check No. THIS PERMIT 5 NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATED AUTHORITY. THE PERMITSHAL,I BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABANDONMENT ACTIVITIES. nFP Fnrm• 6?-. q.9a0(,1 Inearnarated in 62-532.400fl). FA.C. Effective Date: October 7, 2010 Page 1 of 2 BENCHMARK NO. 1 1 I MAG NAIL & DISK 3D' I 30' STAMPED "LB 78057 I ELEVATION 15.97 FEET (NAVD 88) I LOT 7 " I (OCCUPIED) F.F.E. 17.92 .FEET ' 04' 1 FENCE CORNER WOOD PUMP I I 0.68' NORTH o�HOUSE - '�� Q x16 °h6 I FE CE X N89' T01 "E 220.00' " 166 X�y PROPOSED IRRIGATION 1 WELL PUMP PROPOSED 1 coI 20' CONC. 1 M DRIVEWAY IRRIGATIONPR OSED 1 RIGATION LINE s1.7• 70.22' / ~ 3 Ld I } z io W 7g RAOIUS o Q O Q I Q T S o 0 N'\ ay o ,h k131 T) 13.7' �5 o x �, Z o_ b CAN �LZ— x 17.7' .-o ff>r, �h'3 Z�Q ►3 inn \ h ��, 3.0 / x1 = _ �fa O N DESI no a PROPOSED p U I� Q F- PROPO ED v W CONC. _ — — vN = LOT 8. CONC. 10.0' x 00 cn .. PATIO (n M Cn N FOUR, PORCH a a / I� O M I PROPOSED 2O'X55' SEPTIC THERE I I PAGE(; DRAINFIELD AREA D & CAP 3. I LUCIE �L J ti ti10 16e c o - — — — — 30.00 1 AIN LINK IF E x S89'ST(i 200� �`ti x O x (l(-_ x ,�1659' 9=E 600 FENCE CORNER E / ea SURVEY( LOT 9 2.88 SOUTH I �y' 1. REPRODUC ESTATES RAISED SEAL ,OR (OCCUPIED) FOUND 5/8" .IRON ROD &CAP I N 2 ADDITIONS (PAGE 49 F.F.E. 19.05 FEET STAMPED "PSM 5543" c f6 �-•� OR PARTIES �Ounty w °0�0 3. LANDS SH BENCHMARK NO. 2 Q 1OTHER INSTRI )a1th MAG NAIL & DISK m w 4. UNDERGRC STAMPED "LB 7805" I 15. DESCRIPTIc ;onstructio 00 6. FIELD SUR x�9 ELEVATION 15.88 FEET (NAVD, 88)1 aE,,o0 7. SYMBOLS iite Plans f 'r Nm z I s. THE cErvT! OTHER BEARII 9. OVERALL F J FOUND PK NAIL 10. HORIZON? NO IDENTIFICATION COORDINATE ADJUSTMENT 11. BY GRAPI CERTIFIED TO FLOOD ZONE G HIC SU AND TOPORVEY AS SHOWN GRANDE CONSTRUCTION. FEMA) ON FI SURVEY MADE! UNDER MY DIRECTION AND CHARGE ANDSAID AND CTION, INC.WCDATE OF FEBI El BEST OF KNOWLEDGE AND BELIEF. I FURTHER CERTIFY. THAT COUNTY PR% ICABLE STAND DS OF PRACTICE FOR SURVEYS SET FORTH BY (N D 88) IOP SURVEYORS I D MAPPERS IN CHAPTER W-17, FLOR104 (NAVD 88) A� UION 472.027, FLORIDA STATUTES. FEEL. 13. NO OBSTf I PHONE (772)323-2244 REVISION: 07/31/18, MOVED PROPOSED DRAIN FIELD. SURVEYOR'S NOTES. ' DATE OF 51GNATURE HEN OI1 COPYRIGHT'© 2018 ALL RIGHTS RESERVED A Tradition of Innovative Engineering CMLSURV DESIGN GROUP, INC. FORT .PIERCE, IFlo da, 3 950 NUE L'B' Nc III