HomeMy WebLinkAboutISSUANCE OF WATER WELL PERMITSMission: Rick Scott
I To Prolact• promote & irr}xwe the health Governor
Pfaff pmpla in Fiartda through integrated
state, cotmtya canmunityefforts E' °.T C ' ' Cer&stc Phi -lip, MD, MPH
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H LEMA IL1 I'i State Stlrgem General and 5eaelary
Vision: To ha the Healthiest State in Oro Nation
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Florida Department of Healfh :in S.L Lucie Co�unfy�
Conditions for issuance of i atbr W,-bJlR,,e, rrilts�:;i
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Effective July 24, 2017
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• Contact the Florida Department of Health in Saint Lucie County (FDOH — St. Lucie)
prior to constructing or abandoning any well.
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a. Cali the FDOH — St. Lucie Well Line at 772-873-4936 or email
SLCDOH-WELLSPFLHEALTH.GOV
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b. Provide the following information:
i. Permit number
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ii_ Driller name
iii. Address
iv. Date and time to begin construction/abandonment
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• I A minimum of 24 hours' notice is required before constructing an q g y 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-WELLSCa7FLHEALTH.GOV
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Submit revisions to permit andlor site map and associated fee within 48 hours of well
i construction or abandonment,
Florida Department of Health
SL1 Lucie County • plvlslon of Disease ConVot and Health ProtecOon
Bureau of Environmontal Health
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Pod t. Uxle, FL349 Accredited Health Department
Port St. 2 772 F734983 public Health Accreditation Board
PHOtdE: 777J873•dg3t •FAX: 772/5g5-1306
FtoiridaHealth.gov
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RECEIVED
SEP 0 5 2018
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„ucie county, PePtTlli! ng
FILE
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STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
ti 'r
17 Southwest PLEASE FiLL OUTALLAPPLICABLE FIELDS
❑Northwest Required Fields Where Applicable)
3 m
U St. Johns River
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p
77iowatarltic,Ycantrctoris ndittbJforsa bGYt
t1South Florida
penn'tappkrcal
thisronnarx7rorvmraing- the bMe
I i Suvlannee River a pffeabkF
i.J DEP
U Delegated Authority (if Applicable)
6_SF- 1 �`�a 333rn
Pamtil No. �� -� I { 3_
Florida Unique ID
PcnnitStlptdations Required (See Attached)
62-624 Quad No. Delineation lib.
CUPIMP Application No.
IV,lez-,r
Owner I Name d Corporation `Address -City •state 'ZIP 'Telephone Number
WON Location -Address, Road Name or Number, City
3! Lt l7!] W5 7_ - 0( 30 -c o o-Q _
J `Parcal 10 No. (PIN) orAltcmate Key (Circle One) Lot Blocic Unit
4,1. r 'may �iv..Ll� 'jpE 5 � � tr-t e', Nl/h Ctuctk i162-524: _Yes No
Section or Land Grant Township `Range 'County Subdivision
s.,Ja,. A Leo^Ar.�S' E.-eiI nr:N,' �_5 —�6� G23 91gI
'Water r Welt Contractor 'License umber 'Teleptiarte Number Email Address
6.1 ."T7124 nil'-_ �f`' 4 A,Y• n&coe-,& AI.- o G-1
7. i Type of Work:S/ Construction Repair _AAadifica6on �Abandonmeni
8.iNdmberofProposed YkIls / RsnsonfcrRope&,rlwlifr�ttdyarAyaraiaMtfor!
S. "Specify Intended Uses) of M11(s): ittl r
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Domestic 'Landscape Irrigation Agricultural Irrigation Site Investigation 1+=J
Bottlod Water Supply _Recreation Area Irrigation _Livestock Monitoring
Public WaterSupply (LimitedUselDOH). _ —Nursery Irrigation _Test Q�G 0
I Public Water Supply (Community or Non-CommunityfDEP)—Commerdatltnduslrial _Earth -Coupled Geothermal 201$
I 'Class I Injection ,..—Golf Course Irrigation _HVAC Supply
I HVAC Return
Class V Injection: —Recharge _Commercialllndustlial Disposal Aquifer Storage and Recovery _Drainage
Rt§mediation: _Recovery _Air Spargo —Other (DesxiUb) O" in St Lude Cou
other roea�ae, ViRONIVI&WAiNj A
. Mom: Not al tipye ot•wolo 3r0I)-"ad ay n 0~ IWM4fin9 mW,,gitYl
I WDistaince from Septic System If s 20D ft- V�� 11. Faculty Description r%e, t-'I 12_ Estimated Start Date
13'Estimated Well Depth ` ft. •Estimated Casing Depth L_2 3, fL 'Prmary Casing Diameter _ 'a9._ in. Open Hole: From
14. Estimated Screen Interval: From To ti. y^
15.-Onmary Casing Material: Black Stool —r'` Galvanized PVC Stainless Steel
I Not Cased Other:
16. Secondary Casing: Teloscope Casing Liner Surface Casing Diameter / In.
17. Secondary Casing Material; Black Steel Galvanized ✓,PVC Stainless Steel Other
IWMethod of Construction, Repair, or Abandonment: Auger /Cable Tool Jetted Rotary Sonic
Combination Mvo or More Methods) Hand Driven (W(all Point, Sand Point) Hydraulic Po nt (t?irect Push)
I Horizontal Dnlling Plugged by Approved Method Othertaedcf�a,
19. Proposed Grouting Interval for the Primary Secondary, and Additional Casing:
From To Seat'Matelial L_ Bentonite Neat Cement_ Other )°
From To Seal Material L,e3entonile, Neat CemenL _Other 1
From To Seal Material L_Bentonite Neat Cement Other )
Fran To Seal Material L_Bentonite Neat Cement. Other }
20. Indicate total number ofexisting "is onsite 0 List number of existing unused welts on site �
21: Is this well or any existing well or waterwithdsawal on the comer's contiguous property covered under a ConsumpWoNVatar Use Permit (CUPArvuP)
or CUPANUP Application? Yes 1�No If yes, complete the following: CUP/WUP Dto. District Well ID No.
22. Latitude Longitude
23. Data Obtalned From: GPS t.1ap Survey Datum: NAD 27 NAD 83 WG5 84
I hefe7y Certifymat I wl tangr-th llc+epuooio I ke orrit 40, FhraaAdit.AV.tti. Code.aryl Ihdpa. xr fuuiNtbr, am voc ner aa•a uaa.ry. met m. �r r�eee rrwawua�n,raaa, and tnN.tu......v m,.,, w pux,r'amot dd.w,o.paa,,,.a,.l.,.,eea„w»uen. or Nk ea ufbae9a plwwwmmmwner[ra rm rerpaidxalcav xr�r ipnr373. F4fkt�oto7.tm. t. nanCln or Vcpntr'a=amanimsei, a.IttMry 7,aftan
s: "'ia^ Irufhd tent, hat at hUmafoe gms,}wf in d,® appkain is kxwsw ant 1hrt twit ottsn ka aQe kr ll,.-W.1h,ltta intruWix,pc,k6d4a��,�n� MI I hwe Wormed theamyq(Nd
ro>A'sra0' a{qm+at CynglMrr4'3@ltt, f157a, ar kml go.prrnotln N a gue, l area na pwiJn a.eN iaa - dyed above. 4nnor mt =1. mtr.: n.f of the Vwo ar De bsswkn:t szwi to pemr'royv.l eerrDdrwt v.+hit aOWryak.r smyx�et lfw corm:mar, Itiow, rawik.6--. nr n,. •14ia,ha ewa tnmo.% Moak,, rrodfauc.r ot�.e arpnma Wzod or tris Pork r t�ra��'aadza, N rtia f+amoY nrhrt Fcmil adlatlpa vd:drwr acucs f.q
APProvalGranted Ely lesueoute ExplratimDate 2 lHydrologist
apt Approval
MioM
Fee Received S Remelpt No. Check No.
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THIS DERAAIT IS NOT VAUD UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRES'ENTATNE OF THE WMO OR DELEGATED AUTHORITY. THE
PERMIT SHALL 66 AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICATION, OR ABAWONhtENT ACTIVITIES.
=ORM LEGR.040.01(6110) This permit is vaNd for 90 days f = the data of rxxua 1T L erua o , n. ,. r c
C
�} P"N'f
a
EXISTING \
WELL
/ x 2.0.83
3
S 8 9055' 43'' E
7 5.0'
19,50 0 PRO
d- .
WELL
x 20 23
x 19.05
Cf1NCRET.r . , •2S, , �--
PARKING co
x 19.55 /
33.
• � <�� 19 ,18 P 4� °$
PARCEL � 140 7-432.- 0 03 0- 000-8 10 3 .5
PROPOSED 1 STORY
(r ! PRSOlO?j ]l�) CBS RESIDENCE
xINI`/YFF �EPTIC 71 (,
a f 7 n