HomeMy WebLinkAboutD O H PAPERWORKIr
A. M. ENGINEERING AND TESTING INC.
3504INDUSTRIAL33�STREET RECEIVE
FT. PIERCE, FLOR[DA' 34946
LOCAL OFFICE: (77 f �1x: (772)46-888MAR 2 1 2006
U{ U BY: g .
REPORT OF FOUNDATION PAD COMPACTION
SCANNED
B
Client: Adelaide Rodrigues Report Date: 3/3/&. Lucey County
Project No: ie
Report No: 8436
Site: 5912 Seagrape Drive, Indian River Estates Permit No. 009-1015
1 St. Lucie County, Florida
Foundation Pad
Density tests and Hand Cone Penetrometer (HCP) readings were made at a minimum of three locations in
the building pad. Density tests were performed in the upper one foot of fill. HCP readings were taken in
hand auger boreholes at one foot intervals from slab grade through the depth of fill. The density tests were
performed in general compliance with ASTM D 2922. The HCP test, in conjunction with information about
the soil type, is empirically correlated to the relative density of subsurface soils.
Density
Test No.
Date
Tested
Location
Elevation
feet
D Mm c
Percent
Compaction
In Place
Proctor
,8436
3/2/2006
SW Corner
0-1
112.0
116.1
96.5
Center
0-1
111.4
116.1
96.0
NE Comer
0-1
113.2
116.1
97.5
* All elevations are below slab grade.
The depth of the fill was approximately three feet. The fill should extend at least five feet beyond the
building perimeter. At the time of our testing no information was available regarding the foundation pad
setbacks.
In the locations and depths that were tested, the fill has been compacted to a minimum of 95 percent of the
modified Proctor maximum dry density (ASTM D 1557). No soil borings were performed below the
recently placed fill.
Distribution:
Client — 1
SLC Bldg. Dept. - 1
Submitted by:
ENGINEER[ AN _SNTi iG/ L
fOrid
cNEa GrantA coliEa Registration No. 51863
S.-Wort Pierce OfceWetAppsUTTLE LOG BOOKWouse JobsWisc. House Jobs lSaint Lucie CountylRodrigues(8436)5911 Seagrape Dn.doc
STATE OF FL,,
DEPARTMENT dr- REALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter,IOD-6,
APPLICANT: AGENT:
PROPERTY STREET ADDRES n^
PERMIT
RECEIPT #
FEE PAID S
AID
PAC
r
LOT: G BLOCK: ' n rn SUHDIVISION:
PROPERTY ID #: (•� l•[� [SECTION/TOWNSHIP/RANGE/PARCELNUMBER] -
[OR TAX ID NUMBER]
CHECKED'[X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 1011-6, FLORIDA ADMINISTRATIVE CODE.
TANK INSTALLATION SETBACKS
[ ] [01] TANK SIZE (1] IDO [2] [ ] [27] SURFACE WATER
[ ] [02] TANK MATERIAL [?paL
[ ] [28] DITCHES
[ ] [03] OUTLET DEVICE f,,.yt,.4c.- [ ] [29] PRIVATE WELLS
[ I• [04] MULTI -CHAMBERS Y [ ] (30] PUBLIC WELLS
[ ) [05] LEGEND MQ(60-69j1-CD;
[ ] [31] IRRIGATION WELLS
[ ] (06) WATERTIGHT [ ] [32] POTABLE WATER LINES
[ ] [07] LEVEL
[ ] [08] DEPTH OF LID [ ] [33] BUILDING FOUNDATION
[ ] [34] PROPERTY LINES
[ ] [35] OTHER
DRAINFIELD INSTALLATION
[ 09 ] AREA [ 1 ] 32 Q4 (2 8 SQFTT
[10] DISTRIBUTION BOX/ [
[ 11 ] NUMBER" OF DRAINLINES
[12] DRAINLINE SEPARATION [
(13] DRAINLINE SLOPE [
[14] DEPTH OF COVER
[15] SYSTEM ELEVATION(��'_
[16] SYSTEM LOCATION [
(17] DOSING PUMPS
[18] AGGREGATE SIZE f [
[19) AGGREGATE SOURCE
[20] AGGREGATE WASHED [
[21] AGGREGATE DEPTH [
FILL/EXCAVATION MATERIAL (
[22] FILL AMOUNT [
(23] FILL TEXTURE
(24] EXCAVATION DEPTH
[25] EXCAVATION AREA [
[26] REPLACEMENT MATERIAL F
OF
'ONSTRUiTION APPROVED ISAPPROVED]:__I�:
FINAL SYSTEM [APPROVED/DISAPPROVED]:
0H 4016. 9/96 (Replaces HRS-H Farm 4016 (page 21 Whlch may be used)
)Slack Number: 574/•002-4016J)
FILLED/MOUND SYSTEM
] [36] DRAINFIELD COVER '
[37] -SHOULDERS - -
] [38] SLOPES
] [39] STABILIZATION MATERIAL
ADDITIONAL INFORMATION
(40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] PLUMBING FIXTURES
[46] FINAL SITE GRADING 1.e
[47]CONTRACTOR
[48] OTHER
ABANDONMENT
[49] TANK PUMPED
[50] TANK CRUSHED AND FILLED
/", DATE:
DATE:
Page 2 of 2
APPI ((ANT
STATE OF FLORIDA CENTRAX #: 56-SF-08410
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT - RECEIPT
OSTDSNBR 05-0515- -N
CONSTRUCTION PERMIT FOR:
[ X ]New System [ ]Existing System [ ]Holding Tank
[ ]Rep,ir [ ]Abandonment [ ]Temporary
APPLICANT: Rodrigues, Albertino & Adel a AGENT: ROLAND
PROPERTY STREET ADDRESS: Seagrape Dr Fort Pierce FL 34982
LOT: 5 BLOCK: 66 SUBDIVISION: Indian River Es
PROPERTY ID #: ---
e
[OR TAX ID NUMBER]
] Innovative Other
1
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E-6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ]Gallons SEPTIC TANK
MULTI-CHAMBERED/IN SERIES:
[Y ]
A [ 0 ]Gallons
MULTI-CHAMBERED/IN SERIES:
[Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ] GALLONS DOSING TANK CAPACITY [ 0 ] GA//LLONS @
[0 ] DOSSES PER 24HR�S/ # PUMPS[
0 ]
D [ 462 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM "< q 1
0 �/
R [ 0 ] SQUARE FEET SYSTEM ✓✓
A TYPE SYSTEM: [ Y ]STANDARD [ N ]FILLED
[ N ]MOUND [ N ]
I CONFIGURATION: [ N ]TRENCH [ Y ]BED
[ N ]
N
F LOCATION TO BENCHMARK: C/L of Road ® South Property Line
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [ INCHES
] [ ABOVE] BENCHMARK/REFERENCE
POINT
E BOTTOM OF DRAINFIELD TO BE [ 11.0 ] [ INCHES
] [ ABOVE] BENCHMARK/REFERENCE
POINT
L
D FILL REQUIRED:[ 4.0 ]INCHES EXCAVATION REQUIRED: [
84.0 ] INCHES
OTHER REMARKS:
The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with s. 64E-6.013(3)(f), FAC. SCANNED
Home stubout invert to be 23 inches above reference point. BY
Excavate 41'xl4'x7' deep. St. Lucie County
k
i
SPECIFICATIONS BY: POLISSKY, JODI TITLE:
APPROVED BY: Polissky, Jodi TITLE: Environmental Spec
St. Lucie CHD
DATE ISSUED• 8/26/05 EXPIRATION DATE: 2/26/07
DH 4016, 03/97 (obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) [ostde cone_4016-11 Page 1 Of
1xe
-' 4^. STATE OF FLORIDA CENTRAX #: 56-SF-08410
DEPARTMENT OF HEALTH OSTDSNBR : 05-0515-N
w� ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Rodrigues, Albertino & Adelaid
AGENT: R'OLAND ROLLINS
LOT: 5 BLOCK: 66 SUBDIVISION: Indian River Estates ID#: ---
s
YTO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S
MUST PROVIDE REGISTRATION NUMBER AND SIGN WIM PRLT. EACH PAGE OF SUBMITTAL,OM A T TTRM
M
PROPERTY SIZE CONFORMS TO SITE PLAN: [XI YES [ ]NO NET USABLE AREA AVAILABLE: 0.23 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [64E-6, TABLE 11
AUTHORIZED SEWAGE FLOW: 345 GALLONS PER DAY [1500GPD/ACRE OR 2500PPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1000 SQFT UNOBSTRUCTED AREA REQUIRED: 857 SQFT
BENCHMARK/REFERENCE POINT LOCATION: C/L of Road ® South Property Line
ELEVATION OF PROPOSED SYSTEM SITE IS 25.00 [ INCHES ] [ ABOVE ]BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: N/A FT DITCHES/SWALES: 15 FT NORMALLY WET? [ ]YES [ X ]NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: 75 FT NON -POTABLE: N/A FT
BUILDING,FOUNDATIONS: 5 FT PROPERTY LINES: 11 FT POTABLE WATER LINES: N/A FT
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SITE ELEVATION: 0 FT NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell #/Color Texture Depth
lnVR-9/4-RN Finn Rana n to 24
lnYR=4/1-n QY Finn Rana 24 to '19
101R-6/1-GY Finn Rana '{fi to 5n
10VR-7/1-T. QY Rine Rana Sn to rn
lnVR-2/l-RR Hardpan 6n to rr
1nYR-2�1-RE Rnfnaal 66 to 72
hn
USDA SOIL SERIES:
to
21 Lawnwood San
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture Depth
10YR-5/1-RN Fine Rana n to 24
1nVR-4/1-n ry Rona Rana 24 t0 36
lnVR-7/1-T. f7Y Rino Rana 76 to 5R
1 nVR-2/1-R8 Hardpan r,R to 62
IOYR-2/1-BK Refusal F2 to
to
to
to
USDA SOIL SERIES: 21 Lawnwood San
OBSERVED WATER TABLE: 56.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [PERCHED ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:38.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO ` ,DE�PTW: 0.0 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:Fine S,
DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED
f!EMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY: JOHN HANSON
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stack Number: 5744-003-4015-1) [ostds_eval 4015-3]
: 84.0 INCHES
DATE: 8/22/05
Page 3 of 3
APPLICATION; FOR:
[ ] News' System
[ ] Repair
N. \
STATE OF FLORIDA
'.DEPARTMENT OF ,HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
'APPLICATION FOR 'CONSTRUCTIONPERMIT
Authority: Chapter 381, FS B Chapter 1OD-6, FAC
[ ] Existing System
[ ] Abandonment
APPLICANT:
AGENT:
I
MAILING :ADDRESS
111
PERMIT 11
DATE PAID
FEE PAID
RECEIPT #
[ ] Holding Tank [ ] Temporary/Experimental
[ %] Other(Specify) -
G�il 'Q F-IJrXCr, (^P TELEPHONE ���'S ��'�,�y� .%6
�',G,d 46(v&71 (r,
20 UJ irL( i -\
FL ?
TO BE COMPLETED BY APPLICANT OR. APPLICANT'S AUTHORIZED AGENT..-. ATTACH BUILDING; PLAN ,AND TO -SCALE,
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6:; FLORIDA ADMINISTRATIVE CODE.
_ _________ _____ _____ _____ ___ -====
---- ----- ----- ----- -----
PROPERTY,.INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL,. DESCRIPTION. OR DEED]
6 6 -, qh
LOT;' BLOCK: U/ �' SUBDIVISION: 1%✓` (G�f e-cCc; (G. $.{/lyli7� SUBDIVISION:
PROPERTY ID #:. [Section/Township/Range/Parce�l/ No.], ZONING:
PRUPERTY�SI SIZE: Z ORES flSgft/43560]� PROPERTY WATER SUPPLY: ['iC] PRIVATE, ,[ ] PUBLIC
y y(J jj j \ j %J//� i \
l L,/. � 1 , .�E f-. I i� 1 YI • MTV
LPROPERTY .STREET ADDRESS:
DIRECTIONS TO PROPERTY: ,/' 4F -.//�• ,
tr
�. BUILDING' INFORMATION RESIDENTIAL [ ] COMMERCIAL
Unit Type of \ No. of Building # Personol B 'n E1s c9' 't
No Establishment. Bedrooms. AreaSgft Served F i [ nl vr
2
F
3
4'
I
-[ ]. Garbage Grinders/Disposals
Ultra -Tow Volume Flush Toilets
APPLIC :'S SIGNATURE:
DH 4015, 10/96 (Replaces HRS-H Farm. 4015 [Page 1] which may be,used)
(Stock Numblir: 5744-OOl-4015-1)
Hot Tubs Floor/Equipment Drains
[ Y{jGthd`r (Specify).
' h�/zo7 A DATE: "'n1.05
n
i P . • ,
Page 1 of 3
INSTRUCTIONS
APPLICATION FOR:
F
Check type of permit, if 'Other' specify type in blank. ^•
APPLICANT:
l
M'
Property owner's full name.
I
TELEPHONE:
Telephone number for applicant or agent.
AGENT:Property
owner's legally authorized representative. ,I
MAILING ADDRESS:
P.O. box or street, city, state and zip code mailing address for applicant or agent.
LOT,.BLOCK,
i
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
SUBDIVISION:
legal description or deed must be attached,
DATE OF SUBDIVISION:
Official date of subdivision recorded in county plat books.(month/day/year) or dale lot originally recorded. Dividing ��In approvell
lot into two or more parcels for the purpose of conveying ownership shell be considered a subdivision of the lot. III
PROPERTY IDN:
27 character number for property. (Health Department may require property appraiser ID# or section/township/range/parcel number.)
PROPERTY SIZE:.
Net usablearea of property in. acres (square footage divided by 43,560 square feet) exclusive of all paved areas and p!ipared road
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacled road rights -of -way and easements with no subsurface detractions
may be included in calculating lot area. II'
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
.DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table 11, Chapter IOD-6, FAC. Examples: single family, single wide mobile home,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected. to routinely provide sleeping accommodation for
occupants.
BUILDING AREA - Total square footage of enclosed habitable area of dwelling unit, excluding garage,carport, exterior storage shed, oropl n or fully
screened patios or decks. Based on outside measurements for each story of structure.
d PERSONS: Number of persohs residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed. II'
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operetion, or ocher information required by
Table 11, Chapter IOD-6, FAC. III
FIXTURES: Mark each listed fixture with number installed or 'NA" if not applicable. �I
SIGNATURE: Signature: of applicant or agent. Date application on day submittedto Health: Department with appropriate fees and attar' meets.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions„locations of residences or buildings, swimming pools,!I corded
i
easements; onsite sewage disposal system components and location, slope of property, any existing or proposed wells, J�ainege
re featus, filled areas, obstructed. areas, and surface water. Location ofwells, onsite sewage disposal systems, surface well tars, and
I If
other pertinent facilities or features on adjacent propert}, if the features are with 75 feet ofthe, applicant lot. Location of any
public well witfiin.200 feet of lot. �
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresident
establishments, a floor planshowing the square footage of the establishment, all plumbing dmins and fixture types, and
features necessary to determine composition and quantity of wastewater.
APPLICANTe A'
LOT:
PROPERTY ID#:
STATE OF FLORIDA
DEPARTMENT OF HEALTH '
ONSITE SEWAGE-DISPOSALSYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
( G
PERMIT #
Fes/ flJ l�
[Section/Township/Range/Parcel No. or Tax ID Number]
e
=voc=======v=====_=====5====vo==c====e==oe=_===c=c==occc=====oo=====c==========v=====o======v==.c=
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON.. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS'.
.PROPERTY SIZE CONFORMS TO SITE PLAN: [ I YES [ ] NO NET USABLE AREA AVAILABLE': O.wS ACRES
TOTAL ESTIIMATED SEWAGE FLOW: 3t�(}'' GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: 3� GALLONS PER DAY [1500 GPD/ACRE. OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: ) Z� SQFT UNOBSTRUCTED AREA REQUIRED.: 9,2 g SQFT
BENCHMARK/REFERENCE POINT' LOCATION: t' -4 G rC,.. � c'Ca / l/'�'Lf
ELEVATION OF PROPOSED SYSTEM SITE IS /. 'I- [.INCHES/(fP] - OV /B OW] BENCHMARK/REFERENCE'. POINT.
CI f ( JPprj_77,
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:.
SURFACE WATER: �j �I FT DITCHES/ EW ES.: �lT, FT NORMALLY WET7 [ ] YES [ ] NO
WELLS: PUBLIC: '%..J� T LIMITED USE:' .1, � �yy.FT P! VAT^E ��.S��-"JFT.. NON=,PO� LE.: �C_� FT
'BUILDINGiFOUNDAT:IONS: FT PROPERTY LINES: i.! FT POTABLE WATER LINES.: i./(J FT'
r:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 101 YEAR FLOODING? [ ] YES •[ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
AGVbz 9
SOIL. PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE.2
Texture Depth
-
to
to
to
to
to
to
to
SERIES:
Munsell #/Color Texture Depth
to
to
to
to
EORR to
In
11 to
to
to
USDA SOIL SERIES:
OBSERVEDi;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' [ j '.NO DEPTH: INCHES
Y
'SOIL TEXTURE/LOADING RATE FOR
DRAINFIELD CONFIGURATION.: [
REMARKS/ADDITIONAL CRITERIA:,
SITE EVALUATED BY:
J�'J ' r r DEP716QK/�RCAtVbS1W1: INCHES
] BED [ ] OTHER (SPECIFY]
OH 4015; 10196 (Replaces NRS-H Form 4015{Page 31 which may be fused)
(Stock Number. 5744-0034015-1)
Page 3 of 3
INSTRUC NONS'
PERNIIT NUMBER:
APPLICANT
AGEN r:
LOT. flLocK, sUBmvisioN
Permit tracking number by County Health Dcpartmenf.
Property owner's full name.
Property owner's legally authorized mpresentative.
Lot, block. and subdivision for lot.
PROPERTY ID NUNIBER: 27 character number for property (property appraiser ID number or section;towash iprrang'parcel number).
PROPER I Y StZE: Check. if property at site conforms to, submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way of easements and exclusiveof sid iris, lakes.
normally wet dralnaec ditches, mmshe;_ or other such bodies of water. '
SEWAOT'. FLOW. Record the estimated sewage flow for the establishment from Table I (residence) or'fable 2 (non-resi8entiai),
Chapter (OD-6. PAC. Record the authorized sewage flow for the lot based on net usable area and water supplyi
(1500 "allons per day per acre for private water supplies and 2500 gpd per acre for public water. supplies). If
uuthorized sewage flow dotes not equal or exceed the estimated sewage flog, the application must be denied.
UNOBS I RUC I FD AREA. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be: at
leasi 2 limes as large as the drainficld absorption area and at (cast 75 percent of the unobstructed area must meet
nnnlmmn setback, in Chapter IOD-6. PAC. The unobstrueed area mint be contiguous to the drainficld.
1I
BENCHMARK INFORNIATION Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation Record the
elevation of the proposed system site in relation (above or below) to the benchmark
I
MINIMUM SETSM'KS: Record minimnm xetbackswhich can be meet to oil listed features- Actual measurements mu,t be recorded or
..NA., foftatyuxs. Features On site plan or within 75 feet of the applicant lot must be riceasured.
'Cite location of any public' drinking well within 200 feet of the. applicant's lot must also be verified.
I�
f LOOD INI URMATION Record information on lots subject to flooding. For lots subject to flooding record 10 Near flood elevation for
site and. actualsite elevation.
SO❑. PROI ILE,INFORMATION: No soil profiles within the proposed ah,sorption area to u minimum depth of b feet or rc £teal are required. Soil
identification will use USDA Soil Classification methodology (Nlunsell colors and USDA soil Lexttua5). '.tclusals
must he clearly documented. Provide USDA soil series if available. record "UNK" if the series cannot be
determined.
WATER TABU{: Record the depth of the observed water table at the time of the evaluation, Mark `perched" or apparepr" as
appropriate. Record the estimated wet season water table olcvation based on site evaluation. USDA sojl maps.
nod historical information. Indicate tf there is high water table vegetation present. Indicate if nnottling is present
and depth
SQtt. TEXT URE. Rccnrd soil texture or loading rate, feu system sizing.
DI;,PI If OF FXCAVATION: if applicable record depth of excavation required. Record "NA" if not applicable.,
DRAINFIEI D CONFIGURATION. Check drainficld configuration required. If other. specify type.
ADDITIONAL- CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EV ALtCATFD BY: Signature of evaluator. title, and date of evaluation, Professional engineers must seal all documents submitted.
ELEVATION WORKSHEE7'
ELEVATION OF BENCHMARK 1 REFERENCE, POINT IS! _ I�
BENCHMARK
SITE I SHE 2 SITE 3
[ + j SHOT —
11.1. _ 11.1, H.1.
Ill.
(- I SHOT (' T SHOT' __._...__..__ f - I SHOT w__
STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
o4•palr:
o�
REPAIR, MODIFY, OR ABANDON A WELL
Southwest
Northwest THIS FORM MUSTBE FILLED OUT COMPLETELY.
=St. Johns River Tbewa:erwegcontractoris responsible forcompregng this
'ry-n Sa
cob
_ South Florida font andforwardrig the permit to the appmpdate delegated
wET'
= Suwannee River ccunr/ where appgcable.
CHECK BOX FOR APPROPRIATE DISTRICT
PCMmdNo.
SepueNo.
Permit Sul
62-524 well D
CUV
wvp Application No.
F Ot)K!G-u�S .I- �b�•IAiDf✓ P.dbe' df-419'S %!.2-595=J1
1.{}J8EtC7)Nd
Ownet, Legal Name of Entry if Corporation - Address City Zip TerfnsNumher `
Y. . py�2Gl[ 3S/9A?
2. ;S:eg--2ja 2. r
Name, C nd Zi��
Well�Location. Address, oad
77XqQ m6?5, _
WeliaDdl',m�g/ Contractor� P License No. Telephone No. 'NW NE
'It /Y 2R-'t�'� Sf 4. _%of_%of Secton_
J [
Address Isna:w7 (scpsv7 __y___a___.,___
(Indicate Well n Chart) ' r ,
5. Taemshfp Range
Y
City Stale lip ' v' r
6. S? Luc/F �INDfadH yQlfl�C "Nhi_I�I�- ; r
Cocrry Subdivision Name Lot Block Unit SW SE
7. Number of proposed wells, Check the use of well: _ omestic (Res. Home) _ Monitor —Irrigation (Residential)
—Irrigation (Business) . _Public Water Supply (Business) List Other /,
Distance from septic system 7 _�_�It from foundation �ft Description of fall' 17644e '
r �Dinstance
Estimated start of construction dare Plumbing connection: _Sewer Septic
RepaidModifyAWROVED
B. Application for: ✓ New Construction
Abandonment (Reason for abandonment 1
9. Estimated: Well Depth Casing Depth '
Screen Interval from to to Cassg hta:edal: Blk-SI el f Gal f PVCC AUG 2 6 005
Casing Diameter Seal hla:erial NCAirlf'�✓/
� Materialkr' 0 A� J��
10. If applicable: Proposed From O to Seal
Grouting Interval From to�O SealMalariah CL� SfLUCIECOUN FAL EP T
" " 't ' 10'
From N- to Seal Material pdw j( {i
-� 75 4Wdsa drz
Diantl
11: Telescope Casing_ or liner_ (check one)
No'u'
Blk-Steel)Gal=)PVC Other(specct
12. Method of Construction: _ Rotary � Ca_'e Tcol —Combination
_Auger _Other (specify): 13. Indicate total No. of wells on site �. List No. of unused wells n site /i westl rant
Ihis the contiguous prgpbrt/coverd under
FILECOPY
14. Is web or any olherweli br waterwithd2wal on oh-cls
aConsumpliveAVaterUsePermit(CUPMNP)orCUPIMPA;;Eaton? No _Yes
("Yes, complete the following) CUPNVUP No.
District well ID No.
Latitude Longitude Sc� th
Data obtained from GPS _ or map _ or survey _ (mzp datim NAD 27 _NAD 83 —1
15.twtir tat an Oieae"dthe pmpeity, MAeb7ntmram;xmWcdu a ;L, ad"I= a.ae dmr
andMars p&nitaa:tiarWurpapem247needed.tutbemadbeetbimd �esransT+bes �mda ClvC�aP7.nMda SbWNs. to mantanaD�CD�/ratan 0is a.1�'r9ullam
7<areriN�e a+iw.8iA7tNtmaadanpmdded'aamrak. and NatlAa�ahhrtred Pe ccc�daism
prumcamr/cmeNdrd caseau�.cn lMNerwSht Out ap7nbmiaYnTiGed on this
bpSnn neeaewssaapCG�e+al ■rm ctl:er Y=daf0acal apCrst&5ct ac sfMid aba+a 0xneraquentsbperscaat 010ew7A0aanpRsmzNeacsSb Te xe9fae
aeplee7
Cep;ramknexaaavppradde.0bdays
afxrdfirgaS.e Writ ■auLatiaaco¢viF%L /
- �ioaq w&'V� e
Si nature of Contractor License No. owneesorA enrs Si nature =
Approval Granted By:
Owner Number.
Issue Date:
g Receipt No.:
Hydrologist Approval
oa>!a
Check No.:
Inspected by: Date:
THIS PERMIT NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE p ID. .Isis HALL BE r AVABLE days iron TTHE
ialle of)WELL
SITE DURING ALL DRILLING OPERATIONS.
Farm 0123