HomeMy WebLinkAboutPERMIT APPLICATION TO CONSTRUCT REPAIR MODIFY OR ABANDON WELLMission:
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Rick Scott
Governor
To protect, promote & improve the health
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of all people In Florida through integrated
Celeste Philip, MD, MPH
state, county & community efforts.
WEALTHState
Surgeon General and Secretary
Vision: To be the Healthiest State in the Nation
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
Effective July 24, 2017
®
Contact the Florida Department of Health in Saint Lucie County (FDOH — St. Luck
prior to constructing or abandoning any well.
a. Call the FDOH — St. P Lucie Well Line at 772-873-4936 or email
SLCDOH-WELLS(a,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 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(cD-FLHEALTH.GOV
*I Submit revisions to permit and/or site map and associated fee within 48 hours. of well
construction or abandonment.
Florida Department of Health
St Lucie County - Division of Disease Control and Health Protection
Bureau of Environmental Health
5150 NW Milner Drive
Port St Lucie, FL 34983
PHONE: 772/873-4931 - FAX: 772/595-1306
Accredited Health Department
Public Health Accreditation Board
FloridaHealth.gov
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*Parcel ID
5.
*Water we
STATE OF FLORIDA PERMWAPPLICATION TO CONSTRUCT,
REPAIR, MODIFY; OR ABANDON A WELL PerWitN& 5-9-28-75,a�
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0 NoTthWest ("Denotes Required Fields VMere'Applicable) PeWt 'SUPulations Required (S6qAf.Wq
13 SL Johns River . . 11
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2. *Specify Intended Use(g) of %%U(s):
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ed Screen Interval: Fron&/ _T
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Casing Material: Black Steel _VGatvWzed PVC Stainless steel
NatCased _Other,
aly Casing: _Telescppa Casing ,Llner _Surface Casing Diameter in.
arYCOSIng Materfat- ---.BladSWI Galvanized _.✓' PVC -Stainless Steel Other
of-CvntWcg6f�Repair, -orAba6cTonment: Augqr _____Rotary Aonla
:oftiblhaffdn (TWo or More Methods) Hand Driven {Welt Sand Polk) Hydraulic Polk (Direct Push)
4woontallptiffirb —PiuggedbyAp—proved Method Pher(D'
id Gtout(ng lrLtepmj f"SPrimary, Sitzri4aq, and Additional Casing:
XIC*Ietotal numb"ofe)ftungwdllsch site Listnumberof@xisting unused wells on site
1111swellorarve4ptimawev drwaterVdhdrawal 0rithe owner's contiguous property covered under a Corosumptive/Mler Use Permit (CUPAIVUP)
CUPAVUP Application? _Yes
___No if yes, tbmplete the following: CUPANUP N6. Dlstr!dWeJl ID No.
Mde Longitude
ita0.btafiiedF;rom:.—GPS 'Map —Survey Datum :W27 MAD 83 _WW84
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