HomeMy WebLinkAboutD O H PERMIT APPLICATION - CONSTRUCT-REPAIR-MODIFY WELLSTATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, perrttit lVo
REPAIR, MODIFY, OR ABANDON A WELL Septic 140,
❑ Southwest permit Sti Ztimm quired
❑ Northwest THIS FORM MUST BE FILLED OUTCOMPLETELY.
❑ St. Johns River The water wag contredo►is responsible ibrcompleting this 62-524 well 0
q ® South Florida form and forwarding Me Pend1 to the appropiete delegated cup/
❑ Suwannee River county where applicable. wup Application No.
CHECK BOX FOR APPROPRIATE DISTRICT
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1. Walter Saitta ( 2507 S.E. W. Blackwell P.S.L. Ff. 772-337-0448
Owner, Legal Name of Entity If Corporation Address City State Telephone Number
-_1111ou Road P S i E1 34952
Wag Location -Address, Road Nome, Wend Zip NW WE—
3. A&C Welidrtiling 12273 1 46"952
Well Drilling Contractor License No Telephone No.
5017 Hickory Drive 4. my % of sw i. of Section ?A
Address (smallest) (wow)
Ft. Pierce I FI. 134982 1 5. Township 36-S I Range 40-E
city State Zip g
(Indicate Well on Chan)
�6_. St. Lucie St Lucie Gardens 17 ) 37 17
Canty Subdivision Name Lot Block Unit SW SE
7, Number of proposed wells 1 Check the use of well: ® Domestic (Res. Home) ❑ Monitor ❑ Irrigation (Residential)
❑ Irrigatlon (Business) ❑ Public WaterSupphr(Basiness) List Other --
Distance from septic system 75+fL Distance from foundation 25+fL Description of facility res home
Estimated start of construction date 64"ti _ Plumbing Connection Sewer 0-selptte
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. Application for: ® New Construction . ❑ Repair/Modify AP=❑Abandonmerd (Reason.forabandonment ) _
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9. Estimated: Well Depth 70' ft Casing Depth 60' ft
Screen Interval from 60 to 70 Casing Material: ❑81kSteel 10Gal I ®PVC
Casing Diameter 2 Seal Material Portland J U N - i L •t;,;
10. If applicable: Proposed From 0 io 60 SwLlbatasiat Portland
Grouting Interval From to Seal Material
From to Seal Material a Ijl Uwwrt
R end
11. Telescope Casing ® or liner ❑ (check one) Diameter 2' _
Blk-Steel ❑ I Galvanized ❑I PVC ® Other (specify): Nam
1 . Method of Construction: 0 Rorary ❑ Cable Tool ❑ Combination
❑ Auger ❑ Outer (specify):
13 Indicate total No. of wells on site 0. List No. of unused wells on site 0
14. Is this well or any other well or water withdrawal on the owner's contiguous oovered under coat r Easy
a CansrmpfiveMlater Use Permit (CUPANUP) or CUPIWUP Application? No ❑ Yes
(Ifyes, complete,the lolluwtng) CUPAWUP No.
District well ID No.
Latitude Longitude
Data obtained from GPS ❑ or map ❑ or survey ❑ (map datum NAD 27 ❑ NAD 83 ❑) Soiei
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Approval Granted By Issue Date: Hydrologist Approval
Owner Number. Fee Received: $ Recelpt No.: eck No.:
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Inspected by Date2ALVLE
THIS PERMrr NOT VALID UNTIL PROPERLY SI�D BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD. IVAILABLE AT THE WELL
SITE DURING ALL DRILLING OPERATIONS. T fbr 110 day►faew►dare ofieaua.
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