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Home My WebLink AboutD O H PAPERWORKAPPLICATION #:AP1226825 :i 1 "•, C-4" STATE OF FLORIDA 75NTRk �(J PERMIT #:5.6-SF-1662113 DEPARTMENT OF HEALTH DOCUMENT #. F11088416 '15 ONS=TE SEWAGE TREATMENT AND DISPOSAL, SYSTEM �+ CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PATD.10/2612016 •ry�o,pt't FEE PAID:6,5.00 RECEIPT #:56-PID-3130433 I _ APPLICANT: Leon & Judith, Resendiz AGENT[ Telisha Jones ��"AAIhI-� PROPERTY ADDRESS. 231 Sunrise Dr Fort Pierce FL 34945 @J d Au �� LOT: 27,28 &29 BLOCK; B ucle County IUBDIVISION: I Tropical Acres In#: 230860100850002 i CHECKED [XI ITEMS ARE -NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. I TANK INSTALLATION SETBACKS [ ] [01] TANK SIZE [1] 1050.00 [2] L ] [271 SURFACE WATER FT [ ] [021 TANK MATERIAL Concrete [ ] [281 DITCHES 33 FT [ ] [031 OUTLET DEVICE [ ] [291 PRIVATE WELLS 88 FT [ ] [04] MULTI -CHAMBERED [ Y N ] [ ] [30.1 PUBLIC WELLS FT [ ] [051 OUTLET FILTER Polylok.PL-122 [ ] [31] IRRIGATION WELLS FT [ ] [061 LEGEND 1. 01-011-09DC3 2. [ ] [32] POTABLE WATER 50 FT [ ] [071 WATERTIGHT [ ] [33',] BUILDING FOUNDATIONS 7 FT [ ] [08] LEVEL [ ] [34;1 PROPERTY LINES 27 FT [ ] [09] DEPTH TO LID [ ] [35] OTHER FT DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM [ ] [l0] AREA. [1] 528 [2] SQFT [ ] [36] DRAINFIELD COVER [ ] [11] DISTRIBUTION BOX. HEADER X [ ] [37] SHOULDERS [ ] [12] NUMBER OF DRAINLINES 1. 4.00 2. [ ] [38] SLOPES [ ] [131] DRAINLINE SEPARATION [ ] [39:] STABILIZATION [ ]1 (141 DRAINLINE SLOPE [ ] [15] DEPTH OF COVER ADDITIONAL INFORMATION [ ] [16] ELEVATION [ ABOVE / BELOW ]BM 4.00 [ ] [40] UNOBSTRUCTED AREA [ ] [17]. SYSTEM LOCATION [ ] [41] STORMWATER RUNOFF [ ] [18] DOSING PUMPS [ ] [42] ALARMS: [ ] [19] AGGREGATE SIZE' [ ] [43] MAINTENANCE AGREEMENT [ ]I (20] AGGREGATE EXCESSIVE FINES [ ] [441 BUILDING AREA [ ] [211 AGGREGATE DEPTH [ ] [45], L"OCATION "CONFORMS WITH SITE PLAN [ ] t461 FINAL SITE GRADING FILL / EXCAVATION MATERIAL [ 7 [471 CONTRACTOR David Whiteside (Accurate S [ ] [22] FILL AMOUNT I ] [48] OTHER INFILTRATOR Quick4 EQ36 (single [ ] [231 FILL TEXTURE [ ] [241 EXCAVATION DEPTH ABANDONMENT [ ] [25] AREA REPLACED [ ] [491 TANK PUMPED' [ ] [261 REPLACEMENT MATERIAL [ ] (501 TANK CRUSHED & FILLED Comments: Comments are on page 2. CONSTRUCTION [ APPROVED / St. Lucie CHD DATE : 10/26/2016 CONS DISAPPROVED ] Le�Environmental Speci st11 Brian J Ingram (ENVIRONMENTAL HEALTH) i FINAL SYSTEM [ APPROVED / DISAPPROVED ): St. Lucie CHD DATE: 12120/2016 Environmental pec t 11 Brian J Ingram. LTH) (Explanation of Violations on following page) DH 4016, 08/09 (Obsoletes all previous editions .which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0.1 AP1226825 EI,D166V 11 RECEIVED DEC 2 7 2016 lp e.- STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL APPLicATTON # : AP'1225825 PERMIT a:56-SF-1662:113 DOCUMENT #:F110$8416 DATE PAID,;10/26/2016 'FEE PAID:85,00 RECEIPT #:56-PiD-3130433 The.system is sized for 4 bedrooms with a maximum occupancy -of 8 persons '(2 per bedroom), fora total estimated flow,of 400 gpd. 900 gal tank installed. permit,ca.11ed for 1D50 gal. 4x11=44 chambers. 900 ST replaced with 1050 ST. Violation corrected. No further violations, system ok to cover. Contractor notified by phone. Needs final.inspection for mound system. Final system approved. Contractor and building department emailed final approval DH 401�6,.08/0,9 (Obsoletes all previous editions which may not be used) Incorporated:'64E=6.003, FAC Page 2 of 3 EH Database v 1,'0.1 AP1226826 'EID1662113 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT :RMIT FOR: OSTDS New on & Judith Resendiz PROPERTY ADDRESS: 231 Sunrise Dr Fort Pierce, FL 34945 LOT: 27,28 &29 BLOCK: B SUBDIVISION: Tropical Acres PROPERTYIID #: 230860100860002 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] PERMIT #: 56-SF-1662113 APPLICATION #: AP1225825 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1006290 SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.00651 F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE[ OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. i SYSTEM DESIGN AND SPECIFICATIONS T I 1,050 ] GALLONS / GPD Septic CAPACITY A [ ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D I 56O ] SQUARE FEET SYSTEM R [ ] SQUARE FEET N/A SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [X] MOUND [ ] I CONFIGURATION: [x] TRENCH [ ] BED [ ] N F LOCATIO OF BENCHMARK: orange BM nail in disk center of rd center of property I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE [ 11.00 ] [INCHES FT ] [ ABOVE j BELOW h BENCHMARK/REFERENCE POINT [ 4.00 ][INCHES FT ][ABOVE BELOW] BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [33.001 INCHES EXCAVATION REQUIRED: [ ] INCHES o IThes em is sized for 4 bedrooms with a maximum occupancy of 8 persons (2 per bedroom), for a total estimated flow of 400 gpd. T The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance H with s.I64E-6.013(3)(f), FAC. E R APPROVED BY: DATE ISSUED: DH 40161 08/09 Incorporated: BY: Brian J Ingram TITLE: Environmental Specialist I TITLE: Environmental Specialist I CBD Brian J gram FILE VW I 02/24/2016 EXPIRATION DATE : 08/24/2017 (Obsoletes all previous editions which may not be used) 64E-6.003, FAC v 1.1.9 AP1225825 SE986362 Page 1 of 3 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN # A02, Tallahassee, Florida 32399-1703. The Agency Clerk's facsimile number is 850-410-1448. Mediation is not available as an alternative remedy. I Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. i HEALTH PAYING RECEIV PAYMEP MAIL TO: FACILITI PROPER St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 W PERMIT#:56-SF-1662113 BILL DOC #.56-BID-3024175 CONSTRUCTION APPLICATION #.AP1225825 D FROM: Homecrete Homes AMOUNT PAID: $ 515.00 f FORM: CHECK 22310 PAYMENT DATE: 02/19/2016 Leon & Judith Resendiz NAME: Y LOCATION: Sunrise Dr t Pierce, FL 34945 27,28 &29 B Block: ertvID: 230860100860002 EXPLANATION or DESCRIPTION: i -1 - OSTDS Construction Application and Plan Review,New 123 - OSTDS Construction Site Evaluation 126 - O TDS Construction Permit (New or Mod, Amendment) 127 - OSTDS Construction System Inspection 128 - O TDS Construction System Inspection Research Fee 145 - OSTDS Construction Perf Based - Relnspection -1 - Surcharge (All) -1 - OSTDS New Permit Surcharge QUANTITY FEE 1 $ 100.00 1 $ 115.00 1 $ 55.00 1 $ 75.00 1 $ 5.00 1 $ 50.00 1 $ 15.00 1 $ 100.00 VanceMH AUDIT CONTROL NO. 56-PID-2893263 i zt?�Ai St. Lucie County Health Department 5150 NW Milner Dr Port Saint Lucie, FL 34983 HEALTH PAYING ON: PERMIT#:56-SF-1662113 BILLDOC*56-BID-3024175 CONSTRUCTION APPLICATION #:AP1225825 RECEIVED FROM: Homecrete Homes AMOUNT PAID: $ 515.00 PAYMENT FORM: CHECK 22310 PAYMENT DATE: 02/19/2016 MAIL TO: Leon & Judith Resendiz FACILITY NAME: I PROPEK I LOCATION: 2� (Sunrise Dr Fort; Pierce, FL 34945 Lot? 27,28 &29 Block: B 230860100860002 Pro pertyID: EXPLANATION or DESCRIPTION: QUANTITY FEE I -1 - OSTDS Construction Application and Plan Review,New 1 $ 100.00 123 - OSTDS Construction Site Evaluation 1 $ 115.00 126 - OSTDS Construction Permit (New or Mod, Amendment) 1 $ 55.00 127 - OSTDS Construction System Inspection 1 $ 75.00 128 - OS I DS Construction System Inspection Research Fee 1 $ 5.00 145 - OSTDS Construction Perf Based - Relnspection 1 $ 50.00 -1 - Surcharge (All) 1 $ 15.00 -1 - OSTDS New Permit Surcharge 1 $ 100.00 RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-2893263 ' STATE OF FLORIDA g DEPARTIONT OF HEARTS ONSITE SEWAGE TREATMENT AND DISPOSAL s SYSTEM! APPLICATION FOR CONSTRUCTION PERMIT 5LICATION FOR: PERMIT NO. DATE PAID: _ FEE PAID: (' /L Z Z-3110 RECEIPT #: New System [ Existing System j ] Holding Tank j ] InnovitlVa Repair [ ] Abandonment n ^[ ] Temporaxy [ ] ADDRESS: G 356� Lucas � L TO BE COMPLETED BY APPL-ICXgT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST•BE CONSTRUCTED BY A PERSON LICENSED PbASUANT.TO 489.105(3)(m) Oft 489.652p FLORIDA STATUTES. IT IS THE "VP XCANT!S RESPONSIBILITY TO PROVIDE DOCU149NTATION OF THE DATE THE LOT WAS CREATED OR P TED (1&4/DD/YY) 'IF RtQUESTING CONSiDERATIOW OF StATUfTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION f� - y LOT: 9!ZIBL,OM SOBDIVISION: PLAJ'Z'EDs PROPERTY ID #: 030 7 6 01009 000 21,• ZONING: I/M OR EQUIVALENT: [ Y / N ] PROPERTY SIZE: �. ACRES WATER SUPPLt: [ PRIVATE PU$LIC [ ]<=2000GPD [ ]?2000GPD IS SEWER AVAILABLE AS PER 381.6065, FS?` C Y N DISTANM TO SEWER: / LFT PROPERTY ADDRESS: DIRECITIOITS TO PROPERTY: _ INFORMATION Unit Type of No Establishment 1 Fr��= 2 3 4 [ ] SIGN DR 4 PEP [Vj RESIDENTIAL [ ] COMMERCIAL _ No. of . Building Commercial/•Institutional Systeft Design. Bedrooms Area Soft Table 1, Chapter 64E-6, i'AC 08/09 (Obsoletes previous rated 64E-6.001, FAC DATE tions which may not be used) Page 1 of 4 STATE OF FLORIDA APPLICATION # AP1225826 DEPARTMENT OF HEALTH PERMIT # 56-SF-1662113 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE986362 SITE EVALUATION AND SYSTEM SPECIFICATION APPLICANT: Leon & Judith Resendiz CONTRACTOR / AGENT: Homecrete Homes LOT: 27.28 &29 BLOCK: B SUBD71SION: Tropical Acres ID# : 230860100860002 TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: EX ]YES [ ]NO NET USABLE AREA AVAILABLE: 1.04 ACRES TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ] AUTHORIIZED SEWAGE FLOW: 1559.99 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: 1750.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT BENCHMARK/REFERENCE POINT LOCATION: orange BM nail in disk center of rd center of property ELEVATION OF PROPOSED SYSTEM SITE 11.00 [ INCHES / FT ] [ ABOVE / BELOW ]• BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: FT DITCHES/SW ALES: 15 FT NORMALLY WET: [ ]YES [X]NO WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 80 FT NON -POTABLE: FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 25 FT POTABLE WATER LINES: FT SITE SUBJECT TO FREQUENT FLOODING? [ ]YES EX ]NO 10 YEAR FLOODING? [ ]YES [X]NO] 10 YEARI FLOOD ELEVATION FOR SITE: FT[ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2 USDA SOIL SERIES:Pineda sand Munsell #/Color Texture Depth 10YR 2H Sand 0 To 3 10YR 4/1 Sand 3 To 14 10YR 412 Sand 14 To 19 1 OYR 5/2 Sand 19 To 42 10YR 3/3 Sand 42 To 48 1 OYR 4/2 Sandy Clay Loam 48 To 54 HOLE CAVING Refusal 54 To 72 HIGH Wi SOIL T) DRAINFI REM WSWTd Sr Strip) SB1 and SITE EV. DR 4015, USDA SOIL SERIES:Pineda sand Munsell #/Color Texture Depth 10YR 2/1 Sand 0 To 4 10Y 4/1 Sand 4 To 15 10Y 4/2 Sand 15 TO 19 10Y 512 Sand 19 To 42 10YR 313 Sand 42 To 48 10YR 4/2 Sandy Loam 48 To 54 HOLE CAVING Refusal 54 To 72 WATER TABLE: 16.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ] i WET SEASON WATER TABLE ELEVATION., 9 INCHES [ ABOVE / BELOW ] EXISTING GRADE ER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X]YES [ ]NO DEPTH: 9.00 INCHES TURE/LOADING RATE FOR SYSTEM SIZING: Sand/0.80 DEPTH OF EXCAVATION: INCHES 0 CONFIGURATION: I ] TRENCH [ ] BED [ ] OTHER (SPECIFY) MS/ADDITIONAL CRITERIA ermined using USDA WSS and soil borings. i matrix.10YRS/I and 10YR4/2 stripping in 10YR4/1 matrix 10% @ 9" in SB1. 32 11 " below SM. BY: 14- Ingravrian (Title: Environmental Specialist 1) (ENVIRONMENTAL HEALTH) 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC i AP1225825 ElD1662113 DATE: 02/23/2016 Page 3 of 4 v 1.0.2 LOT: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS .5F / t06 2.11.E PERMIT #. f / p,L/ Vycl i j &JrLN D1 2 AGENT: z . BLOCK: SUBDIVISION: / /2 /C� / Ag-e-3 ID #: Z30O L04 OF& 000 ;?,,' ([Section/Township/Parcel No. or Tax ID Number] TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINNEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL_ EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: YES [ ] NO NET USABLE AREA AVAILABLE: 175�0 _r ACRES TOTAL ESTIMATED SEWAGE FLOW: GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE21 AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE] UNOBSTI CTED AREA AVAILABLE: SOFT UNOBSTRUCTED AREA REQUIRED: SOFT ; � C"� /,- BENCHMARK/REFERENCE POINT LOCATION: � / t' d �� ` `^'/ ELEVATION OF PROPOSED SYSTEM SITE IS [�/FT] [ABOVE LOW BZ!!!!�/REFERENCE POINT THE MINIMUM SETBACK% WHICH CAN BE MAINTAINED FROM THE ,ROPROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: `7 - FT DITCHES/SWALES: l7 FT NORMALLY WET? [ ]'YES [ ] NO WELLS: PUBLIC: Zo o FT LIMITED USE : /� G7 FT PRIVATE : �, FT NON -POTABLE : �FT BUILDING FOUNDATIONS: -7, FT PROPERTY LINES: j FT POTABLE WATER LINES: /O FT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ ] YES [ ] NO 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD SOIL PROFILE INFORMATION SITE 1 WNSELL #/COLOR TEXTURE DEPTH TO TO TO TO TO TO TO TO TO USDAISOIL SERIES: SOIL PROFILE INFORMATION SITE 2 MUNSELL #/COLOR TEXTURE DEPTH TO TO TO TO TO TO TO TO TO USDA SOIL SERIES: OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE:[PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ABOVE / BELOW] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY) REMARK'/ADDITIONAL CRITERIA: SITE E` DE 4015, BY: 08/09 (Obsoletes previous editions which m '' ' of be used) Incorporated: 64E-6.001, FAC PATE: 6 /Z% f g /6 3 of 4 If ! Ck Z 2 a STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, :5 F ! REPAIR, MODIFY, OR ABANDON A WELL Tj �j Permit No._- ❑Southwest DNorthwest PLEASE FILL OUTALL APPLICABLE FIELDS Florida Unique ID r I (`Denotes Required Fields Where Applicable) Permit Stipulations Required (See Attached) • DSt, Johns River OSouth Florida The water we# contractor is responsible forcompledng s this form and forwarding the permit application to the ti D Suwannee River 62-524 Quad No. Delineation No. ODEP appropriate delegated authority where applicable, ` S D Delegated Authority (If Applicable) CUP/WUPApplication No. 1. 2GK1 P- -e5 eA,C.) •7- - 2. Owrier, Legal Name if Corporation Z 3 I 5 ! ��1 $ J r 7- �` � +=C 6VI? ct. 'Address 'City •State "ZIP 'Telephone Number 2 l Svc✓f=�5.t �r ev<.c jcC Well Location -Address, Road Name or Number, City 13. Z'jG� -' C i•- Cl O 5 4 - C'UO Z � -7 'Z z`7 Parcel ID No. (PIN) or Alternate Key (Circle One) 4. -54 � r c. � i 2e P r c.�c � eov -e 5 Block Unit Section or Land Grant 'Township 'Ran e 5 Leo N a 9 'County —Subdivision Check if 62-524: Yes _ No s cc t(,��. Z4 �F 7 4s4 — i Water Well Contractor 3 ' ��7- / �Cj `License Number 'Telephone Number E-mail Address I 'Water Welt Contractor's Addrpc� � (�'� G �`'' �� t f=f � • re ,.. _ � tit -j 7• 'Type of Work: � Construction .._Re air State Zt—p P _Modification _Abandonment 8, 'Number of Proposed Wells ! Reason for Repair Modifreabon, 9..rWe 'Specify Intended Use(s) of ►I( or Abandonment �\ Domestic Date Slamp _Bottled Water Supply Landscape irrigationarAgricultural Irrigation Site Investigation % D �{ f� E PP Y _Recreation Area Irrigation _Livestock /ul ��O IV! _Public Water Su I Limited Use/DOH ry Irri ation Monitoring U U1:t PPY ( ) _Nurse g —Monitoring q _Public Water Supply (Community or Non-Communit /DEP Commercial/Industrial 6 y ) — _Earth -Coupled Geothermal 9 ,-_Class I Injection __Golf Course Irrigation HVAC Supply t� � Class V Injection: __Recharge,Comrnercial/Industrial Disposal ---:Aquifer Storage and Recovery Return E B 2 4 2016 ' Remediation: 1Recovery _Air S are ry_Dreinage P 9 _Other (Describe) R Other (Describe) Cntuniee��(1 De 10. "Distance from Septic System if s20D f(. '% D (Note; Not all types Of wags are permitted by a given perm12AA19L��bt "� iu0��9 *lftoo —+�� Cif"V► YG 11. Facility Description •5 e N4 /-e ��A.,; I �. IVEstimated Well Depth / JS ft. 'Estimated Casio Depth �`! t 12. Estimated Start Date r 9 P ft. 'Primary Casing Diameter in. Open Hole: From To R. ia. Estimated Screen Interval: From '9`E To f 6 S ft 15.'Primary Casing Material: Black Steel galvanized PVC Stainless Steel Not Cased -Other: , Secondary Casing: Telescope Casing Liner Surface Casing Diameter in. 17, Secondary Casing Material: Black Steel Galvanized PVC 18.'Method of Construction, Repair, or Abandonment: Auger " Cable Too( Stainless Steel Other Combination (Two or More Methods —"" Jetted Rotary Sonic Horizontal DrillingMob q Hand Driven (Well Point, Sand Point) Hydraulic Point (Direct Push) —PluggedY pproved Method Other (oe=dbe)_ 19. Proposed Grouting Interval for the Primary. Secondary, and Additional Casing: From To Seal Material L__Bentoniter Neat Cement From To Seal Material Other ) From To ( Bentonite Neat Cement Other ) From Seat Material L_,Bentonite Neat Cement Other To Seal Material Bentonite �---•-_ Neat Cement Other ) 20: Indicate total number of existing wells on site List number of existing unused wells on site 21,'is this well or any existing well or water withdrawal on the owner's contiguous property covered under a Consumptive/Water Use Permit (CUP/WUP) or CUP/WUP Application? Yes '7�- No If yes, complete the following: CUPM/UP No. 22. Latitude Longitude District Well ID No. 23. Data Obtained From: GPS h*rfrmaltwema� Map Survey Datum: NAD27 NAD83 WGS84 h Parma a y that I we canary the &"Ir bte Mras of Thda e0. $%,We Ad'atnistratfve Code, and that a water recharge oeth+t4 p needed. hed been erhmb be Obtained Offer to commencement orwetr, r caetty that I am the owner of the orsperry, lost the hdornotibn prOWded is oranota, aria mat I am X%,o,a ar my onsrruninn, r raMw tt'naY mat on Womytiw provided In this appGeatkm is eeeNale ve, that I wan Obtain respoehsa>KGas under Chapter 07a• Florida Statutes- Io maintain or eC.isaN appforrt from olhpr tedaral, SWIn, or tool peremmenb ' livable, I e Ina aeanl for the owner, that the rnro ?orrdsmotipn provttlod is mint art, FPCOn l 1 Chandon Chao -unarms wal, or the or Itanify her I am penrBehm report to ern Distdet wltnah 70 nays weer ewnMml gree to Orovldo a urea responslblt0as as slatad abmo, nwnsrconsanrs to a nar,dnnh^nM iWM,iLM by Ihis parade, Or Ina eansWeden, r.aetr, mosilicad... w ho the: Wed yte du 7 the eonsl tra"'r^9 oe,sonner ertWs Np tO or OotognlM(hy{nar4y ACC05: ! Permit aXDi , Wh{��,v,a Gvar, ng ruOlien, repair, modrr¢a ion a Feel THIS DEP 2 `1y`% 'License No. Granted By omnnnl authoazcu by ma igne uu r rAg Dale Expiration Dale a7 17 Hydrolag)slApproval Receipt No. moors Check No. AIT IS NOT VALID UNTIL PROPERLY SIGNED BYAN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE WMD OR DELEGATEDAUTHO -TALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION, REPAIR, MODIFICAYION, OR ABANDONMENTACTIVITIES. RITy, THE 62-532.900(1) Incorporated in 62-532.400(1). F.A.C. Effective Data: October7. 2010 Issue Date