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Home My WebLink AboutD O H WATER WELL PERMITY r - Mission: i To protect, promote & improve the health of all people in Florida through integrated state, comity & community efforts. . HEALTH 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 -aor -li ins or Issuance of Water Well Permits SCANNED SAP"i Effective July 24, 2017 St Lucie County LST Lucie County, Permitting_ • 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(@,,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(a),FLH EALTH. GOV • ;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 Florida Health.gov t Accredited Health Department Public Health Accreditation Board STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, OR ABANDON A WELL Permit No. 54 ,2,? %`f9 ❑Southwest PLEASE FILL OUTALL APPLICABLE FIELDS Florida Unique ID ❑ Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required (See Attached) ❑St. Johns River The wafer welt contractor is responsible for comple!ing ❑ South Flonda this form and forviarding the permit application to the 62-524 Quad No. Delineation No. ❑ Suwannee River appropriate delegated autliority where applicable. ❑ DFP � CUPNVUP Application No. C?Gelegated Authority (If Applicable) A0145 %uhi-16 p/eahWe r ,rile, Legal Name if Corporation `Address 2. �I C4,M Ri r7-.";) *Well Location -Address, 1 3. 3 �4'9 ^ A -Parcel ID o. (PIN) orAlti 4 '- 'So i orn�J Grant 5. %a //tee/ c. 16. 'Water 1 7. `Type of 8.'Numbe 9. *Specify _Dome _Bottle( _Public _Public _Class Class V INE Other IO.'Distanc 13.`Estimat 14. Estimati 15.'Primary 16. Second 17. Second 18.'Method 19. 20. Indicate 1 21.'Is this wf or CUPA 22. Latitude 23. Data Obti I hamhy, cartlfy I1%111 use panmll ar adferia construction. I fumhe pt or Number, City t to i<ey (Circl One s 1 ST Gucli, nsDip!Range Xoun� ice• C. r a� `License Number let ,I a � ST �Jc )KT 6e, �L r3 yl ��716A- et `State *ZIP *Telephone Number Lot' Block Unit division Check if 62-524: _ Yes 1--*No Qf7 art r E-mail A ddr � �aqe State ZIP Work: V Construction _Repair —Modification _Abandonment of Proposed Wells 'Reason for Repair, Modification, orAbandonmenl ntended Use(s) of Well ): � /1 p tic Landscape Irrigation _Agricultural Irrigation Site Investigation (� Water Supply -Recreation Area Irrigation —Livestock _Site Haler Supply (Limited Use/DOH) _Nursery Irrigation _Test Hater Supply (Community or Non-Cornmunity/DEP) —Commercial/Industrial _Earth -Coupled Geothermal SEP 1 8 2018 _Golf Course irrigation _HVAC Supply Injection —HVAC Return :lion: _Recharge _Commercial/Industrial Disposal ,Aquifer Storage and Recovery _Drainage _Recovery _Air Sparge _Other (Describe) __-____.___._ _ FD H in St Lucia Count _-EN1/ R NRi AW REAL' escribe) -- ;�;y is / (Nate: Not all ly f ,tK� permitted by a given pencilling authority) ] from Septic S stem if s200 ft. ov 11. Facility Des ption r `` 12. Estimated Start Date " r I Well DepthAft. 'Estimated Casing Depth ✓ f, 'Primary Casing Diameter in. Open Hole: From To ft. Screen Interval: From _IP To Aloft. asing Material: Black Steel - Galvanized PVC Stainless Steel NotCased —Other: r Casing: Telescope Casing V eLinef Surface asing Diameter in. Casing Material: Black Steel Galvanized ��VC Stainless Steel Other Construction, Repair, or Abandonment: Auger V Cable Tool Jetted Rotary Sonic nbination (Two or More Methods) Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) izontal Drilling Plugged by Approved Method Other (Describe) iroutin Ir,>I al for the Primary, S ondary, and Additional Casing: To (JSeal Material ( Bentonite Neat Cement Other ) To Seat Material Bentonite Neat Cement Other ) ` To Seal Material L_Bentonite Neat Cement Other ) —To Sea( Material (_Be taro Neat Cement Other 31 number of existing wells on site "r/ List number of existing unused wells on site TJ 3r any existing well or water with wal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) . 1P Application? Yes No If yes, complete the following: CUP/WUP No. District Well ID No. ed From:GPS _Map _Surveyw Datum:NAD 27 NAD 83 WGS 84 rrmply with air applicable ndas of Me 40, Fladdo Admbvnitativu Cade. and that a w amr I ct liry that I omit" owner of that property, gtal Out Intam ation provided is accamte, and that I am nwam of my Aacgo permit, if nuadol. has bean er will be obtained prior to cominancoment of wall rosponallighes under chapter 773. Flonda Statutes, to mafreli or properly abandon this well; a, I Bodily that i am "that all information provided in Oda application is accurate and that I K;d obtabh the agent for the ovmcr, that the inrameorm provided is ocatrate, and that I have (ntomtod the owner of their other federal, state, cr local g . hto, if apasaWa I agree to provide a wall 8sldd 3l1 dogs responsibilities as rioted above. Owner =sent& to allo.vbhp personnel of this WO or Wagered Audrorily area= within altar. rrntdutiur u anstntd tin, repair, moditiatfua, o by this purndr, or the pon i oxytitalio c whl rover o to ns firsL to the wag situ during the construction, repair, modibcagon, or abandonment authorized by rid^, pandl raclor *License No. e/V�D 'Signature of Owner or Agent D e Approval Grained By Issue Date / f( I $ Expiration Date3 lr{ ,11-0 Hydrologist Approval Initials Fee Received S V Receipt No, Check No. i 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: 62-50.900(1) Incorporated in 62-532.400(1), F.A.C. Effective Dale: October 7, 2010 Page 1 of2 1w �+Ly-jrJH.Ylw -•• ' —• " n�OYi sff ead.16•• -,,, wv.'�wiRO ar�;�` 1•$� i . :stfil: I_4 e I' .. — �s tarouCa u.P .�• snw.n ma6° "'v+.°a'+�. , I w'1"M W. ' I �• tm.,rw n. to off .... n,.n .°a salon 'ta rw.n°..n.o... I I I � i nr<n Vnm rh4re r[wrcr .. r�ui•m..-. SITE PLAN ALEXANDER A PIAZZA PShf INC. BOUNDARY SURVEY -.ran' 6 OLEANDER AVENUE '^ P I4nr rlrw SEC 9. MP .6S, RV e6E r¢ A ,titw r Ili 1lr°•nn tµaw rNVra NICHOLAS'& HEA7NER TUBITO I FDOH in St. Lucie County Environmental Health Site Plan Approved for Construction Supersedes All Previous Site Plans for OSMS J'6-155F I$"2.3G & Well #c1 .2$7 Date: i f rb Reviewer: i