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Home My WebLink AboutD O H PAPERWORKSTATE OF FLORIDA DEPARTMENT OF HEALTH `V ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM g CONSTRUCTION INSPECTION AND FINAL APPROVAL eeo�v¢1�- APPLICATION 6,AP1371706 PERMIT a:56-SF-1889444 DOCUMENT s:F11313004 DATE PAm:11/02/2018 FEE PAID:515.00 RECEIPT u:56-PID-3785300 APPLICANT: Justin 8 Chelsea Beebe RFrFNEB AGENT: James Trefelner(Trefelner Construcion Inc.) PROPERTY ADDRESS: 1805 LOT: 4 Ln FortPierce. FL 34945 BLOCK: 8 Permitting Department St. Lucie -County St. Lucie Coun SUBDIVISION: Country Living Estates IDR: 2305-500-0016.000-2 lY CHECKED LXI ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION [ 1 [011 TANK SIZE [11 1090.00 (23 [ 1 [021 TANK MATERIAL Polypropylene [ 1 [033 OUTLET DEVICE [ 1 [041 MULTI -CHAMBERED [Ljj N ] [ 1 1051 OUTLET FILTER Polylok PL-68 [ 1 [061 LEGEND 1. 70-143-11DC3 2. [ 1 [071 WATERTIGHT [ 1 [081 LEVEL [ 1 [091 DEPTH TO LID DRAINFIELD INSTALLATION [ 1 [101 AREA (11 509.4 [21 SQFT [ 1 [111 DISTRIBUTION BOX _ HEADER x [ 1 (121 NUMBER OF DRAINLINES 1. 5.00 2. 1 1 [131 DRAINLINE SEPARATION [ 1 [241 DRAINLINE SLOPE [ I [151 DEPTH OF COVER [ 1 [161 ELEVATION [ -ABOVE / BELOW IBM 20_00 I 1 [171 SYSTEM LOCATION [ 1 [181 DOSING PUMPS [ 1 [191 AGGREGATE SIZE [ ) 1201 AGGREGATE EXCESSIVE FINES [ 1 [211 AGGREGATE DEPTH FILL / EXCAVATION MATERIAL [ 1 [221 FILL AMOUNT [ 1 1231 FILL TEXTURE [ 1 [241 EXCAVATION DEPTH I 1 [251 AREA REPLACED ( 1 [261 REPLACEMENT MATERIAL :o:maent9: Comments are on page 2. CONSTRUCTION I APPROVED / DISAPPROVED 1: FINAL SYSTEM I APpAOVED / DISAPPROVED I: nvirenmenfal S� (Explanation of ViolatSone on £ollaving page) I 7 I I 1 I SETBACKS [271 SURFACE WATER [281 DITCHES 1291 PRIVATE WELLS [301 PUBLIC WELLS FT 46 FT 112 FT FT [311 IRRIGATION WELLS FT [321 POTABLE WATER 43 FT [333 BUILDING FOUNDATIONS 5 FT [341 PROPERTY LINES 27 FT (351 OTHER FT FILLED / MOUND SYSTEM [361 DRAINFIELD COVER (371 SHOULDERS [381 SLOPES (391 STABILIZATION 08/05/2019 ADDITIONAL INFORMATION [401 UNOBSTRUCTED AREA [41I STORMWATER RUNOFF 1421 ALARMS (431 MAINTENANCE AGREEMENT [44) BUILDING AREA [451 LOCATION CONFORMS WITH SITE PLAN (461 FINAL SITE GRADING [471 CONTRACTOR MICHAEL W STUHR(ASHTO [481 OTHER INFILTRATOR Ouick4 Plus EO36 LP ABANDONMENT [ 1 (491 TANK PUMPED [ 1 [501 TANK CRUSHED s FILLED Lucie CHD DATE: 04/26/2019 4TAL HEALTH) Lucie CHO DATE: 08/05/2019 .NTAL HEALTH) DH 4016, 08109 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0.1 AP1371706 EID1889444 Violation Number -t STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE: TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL Com en APPLICATION a:AP1371706 PERMIT a:56-SF-1889444 DOCUMENT a:FI1313004 DATE PAID; 11102/2018 , FEE PAID:515-00 RECEIPT a:56-PID-3785300 The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated now of 300 gpd- Final system approved. Contractor and building department entailed final approval. New ST, filter, and 5x9 long DF installed. No violations, system ok to cover. Contractor notified onsite. Needs final inspection for potable water lines, mound system, gutters, and final site grading. Well inspected at construction inspection. DH 4016, 08/09 (Obsoletes all previous editions which may notbe used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0.1 AP1371706 EID1869444 PERMIT #:56-SF-1889444 APPLICATION #: AP1371706 Qn STATE OF FLORIDA • " .� DEPARTMENT OF HEALTH 3. DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM ' xY�OjW"Z RECEIVED RECEIPT #: DOCUMENT #: PR1181480 DEC 2 6 2018 /P/z-o S/sy CONSTRUCTION PERMIT FOR: CSTDS New ST. Lucie County, Permitting _ FI � � COPY APPLICANT: .lusfin & Chelsea Reehe PROPERTY ADDRESS: TBD Cody Ln Fort Pierce, FL 34945 SCANNED LOT: 4 BLOCK: B SUBDIVISION: Country Living Estates 13 qr^1 }�� PROPERTY ID #: 2305-500-0016-000-2 [SECTION, TOWNSHIP, RANGEStP��ipNUMHlg/ [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, 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. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic new CAPACITY A ( ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMDM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 375 ] SQUARE FEE! R [ ] SQUARE FEE: A TYPE SYSTEM: [ ] I CONFIGURATION: [X] N F MOCATION OF BENCHMARK: Drainfield new SYSTEM N/A SYSTEM STANDARD [ ] FILLED [X] MOUND [ ] TRENCH [ ] BED [ ] BM NiD in CL of Rd, no ID, elev 22.36'. N I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE 'L - !`1 O T H E R [ 12.00 111 INCHES FT ] [ 13.00 1 [FINCHES FT ] line extended E BELOW] BENCHMARK/REFERENCE POINT BELOW]BENCHMARK/REFERENCE POINT m 1 Mu1M U: rltl.UU] INCHES EXCAVATION REQUIRED: [ 4f.UU] INCHES ie system Is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of 0 gpd. e licensed contractor installing the system is responsible for installing the minimum Category of tank in accordance with 64E-6.013(3)(0, FAC. SPECIFICATIONS BY: Brian J Ingram TITLE: Environmental Specialist APPROVED BY: / TITLE: Environmental Specialist II Brian J Ingr _ DATE ISSUED: 11/19/2018 EXPIRATION DATE: DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, PAC v 1.1.4 AP1371706 SE1131382 II St. Lucie CHU 05/19/2020 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 120.669 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 A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. 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. St. Lucie County Health Department ioYl d 5150 NW Milner Dr Port Saint Lucie, FL 34983 HEALTH PAYING ON: PERMIT#: 56-SF-1 889444 eILLDOC#:56-BID-4010063 CONSTRUCTION APPLICATION #: AP1371706 RECEIVED FROM: Trefelner Construcion Inc. AMOUNT PAID: $ 515.00 PAYMENT•FORM: CHECK 1669 PAYMENT DATE: 11/02/2018 MAIL TO: Justin & Chelsea Beebe FACILITY NAME PROPERTY LOCATION: TBD Cody Ln Fort Pierce, FL 34945 4 Lot: Block: B Property ID: 2305-500-0016-000-2 EXPLANATION or DESCRIPTION: QUANTITY FEE 128 - OSTDS Construction System Inspection Research Fee 1 $ 5.00 -1 - Surcharge (All) 1 $ 15.00 -1 - OSTDS New Permit Surcharge 1 $ 100.00 -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 $ 75.00 133 - OSTDS Construction Reinspection 1 $ 50.00 RECEIVED BY: MontanezNM AUDIT CONTROL NO. 56-PID-3785300 pT STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT PERMIT NO. - I"q DATE PAID��`LR� FEE PAID: RECEIPT #: 203Ki� APPLICATION FOR: I New System [ ] Existing System [ ] Holding Tank [ ] Innovative [ ] Repair [ ] Abandonment [ ] Temporary [ ] APPLICANT: Justin and Chelsea Beebe AGENT: James Trefelner TELEPHONE:772-201-9833 MAILING ADDRESS: 1760 Copenhaver Road Fort Pierce, Florida 34945 TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION LOT: 4 BLOCK: B PROPERTY ID #: 2305-500-0016-000-2 Country Living Estates PLATTED: ZONING: AG-5 I/M OR EQUIVALENT: [ No 1 PROPERTY SIZE: 1.03 ACRES WATER SUPPLY: [,/] PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ] DISTANCE TO SEWER: FT PROPERTY ADDRESS: Cody Lane DIRECTIONS TO PROPERTY: see attached -BUILDING INFORMATION [ vI] RESIDENTIAL [ ] COMMERCIAL Unit Type of No. of Building Commercial/Institutional System Design No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC 1 Residence 3 1768 2 3 4 [ ] Floor/Equipment . Drains///�/J[�/] SIGNATURE: Q tr q/ Other (Specify) Garbagegrinders/Disposals DATE: DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated 64E-6.001, FAC Page 1 of 4 STATE OF FLORIDA APPLICATION # AP1371706 DEPARTMENT OF HEALTH PERMIT # 56-SF-1889444 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE1131382 SITE EVALUATION AND SYSTEM SPECIFICATION APPLICANT: Justin & Chelsea Beebe CONTRACTOR / AGENT: TrefelnerConstrucionInc. LOT: 4 BLOCK: B SUBDIVISION: Country Living Estates ID#: 2305-500-0016-000-2 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: 1.03 ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ] AUTHORIZED SEWAGE FLOW: 1545.01 GALLONS PER DAY[ 1500 GPD/ACREOR 2500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: 750.00 SQFT UNOBSTRUCTED AREA REQUIRED: 563.00 SQFT BENCHMARK/REFERENCE POINT LOCATION: BM NiD in CL of Rd, no ID. elev 22.36', N property line extended E ELEVATION OF PROPOSED SYSTEM SITE 12 nn / FT ] [I ABOVE I/ BELOW ] BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: 200 FT DITCHES/SWALES: 50 FT NORMALLY WET: [ ]YES [X]NO WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 75 FT NON -POTABLE: FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 20 FT POTABLE WATER LINES: 5 FT SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO) 10 YEAR FLOOD ELEVATION FOR SITE: FT [ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD SOIL PROFILE INFORMATION STTR 1 SOTT. PROFTT.F. TNFORMATTON STTR 2 USDA SOIL SERIES:Ankona Sand Munsell #/Color Texture Depth 1 OYR 5/1 Sand 0 To 15 1 OYR 6/1 Sand 15 To 28 1 OYR 7/1 Sand 23 To 34 10YR 3/1 Sand 34 To 37 7.5YR 2.5/2 Specie Material 37 To 45 1 OYR 614 Loamy Sand 45 To 72 USDA SOIL SERIES:Ankona sand Munsell #/Color Texture Depth 10YR5/1 Sand 0TO15 1 OYR 611 Sand 15 To 30 10YR 7/1 Sand 26 To 37 1 OYR 3/2 Sand 37 To 41 7.5YR 2.5/2 Spodic Material 41 To 47 1 OYR 5/4 Sand 47 To 58 10YR 613 Loamy Sand 58 To 72 OBSERVED WATER TABLE: 61.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ] ESTIMATED WET SEASON WATER TABLE ELEVATION: 23 INCHES [ ABOVE / BELOW ] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ]YES IX]NO MOTTLING: [X]YES [ ]NO DEPTH: 23.00 INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Sand/0.80 DEPTH OF EXCAVATION: 47 INCHES DRAINFIELD CONFIGURATION: [X] TRENCH [ ] BED [ ] OTHER (SPECIFY) r REMARKS/ADDITIONAL CRITERIA WSWT determined using USDA WSS, soil borings, and topographical observations. 10YR7/1 stripping In 10YR6/1 matrix >10 % with diffuse boundaries starting at 23" in SB1 SH1 12" above SM. SB215" above BM. SITE EVALUATED BY: DATE: 11/09/2018 Ingram, Brian (Title: Env[ mental Specialist II) (ENVIRONMENTAL HEALTH) DR 4015, 06/09 (Obsoletes previous editions which not be used) Incorporated: 64E-6.001, FAC Page 3 Of 4 AP1371706 EID1889444 v 1.0.2 APPLICANT'S NAME: Sus+ n 9ec_ oc / TrI~f.=) nsv° LEGAL L; I certify that there are no potable private wells within 75 feet of the available area for the proposed septic system, that there are no non -potable wells within 50 feet of the available area for the proposed septic system, that there are no wells within 25 feet of a pesticide -treated building foundation, that there are no public wells that serve less than 25 people or less than 15 homes or businesses within 100 feet of the proposed septic system, that there are no public wells that serve more than 25 people or more than 15 homes or businesses within 200 feet of the proposed septic system, that the water line from the water meter or well to the structure is at least 10 feet from the available area for the proposed septic system unless the plans show the line to be double sleeved, that there is not a gravity sewer line, low pressure sewer line or vacuum sewage line in a public easement or right -of --way that abuts the property, that there are no lakes, streams, wetlands, or surface water within 75 feet of the available area for the proposed septic system unless the property was created prior to 1972, that the septic system is proposed on the side of the lot farthest from surface water, that all private wells, septic systems and surface water on adjacent or contiguous land within 75 feet of the applicant's lot are shown on the site plan, that all public wells within 200 feet of the applicant's lot are shown on the site plan, and that the location of building or residences, swimming pools, recorded easements, paved areas or driveways, sidewalks, the general slope of the property, filled areas, drainage features, and surface waters such as lakes, ponds, streams, canals, or wetlands are shown on the applicants lot. The natural grade elevation in the area of the proposed septic system and the benchmark must be shown on the site plan. Please locate the benchmark within 200 feet of the proposed septic system. NOTE: }IUST BE CERTIFIED BY A FLORIDA REGISTERED SURVEYOR OR ENGNEER. d,xs. fi,fmcmr�iceScr�I��rrrragc_p1 CERTIFIED BY: Cj 1GiY �B$ Arvaohd FLORIDA PROFI aSIONAL NO.: L$ a44-71 DATE:-�31-9.IS 1QB ,10.: , - r Mission: To protect. promote & Improve the heallh of all people in Florida, through integrated state, county 8 community efforts. •? tt'�f�rw: HEALTH Vision: To be the. Healthiest State In Rick Scott Governor Celeste Philip, MD, MPH Ian General and Secretary Florida Department of Health in St. Lucie County Conditions for Issuance of Water Well Permits Effective July 24, 2017 • 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-WELLSCf;DFLHEALTH.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 cr.FLHEALTH.GOV • Submit revisions to permit and/or site map and associated fee within 48 hours of well construction or abandonment. DEC 2 6 2018 ST. Lucie Florida Department of Health St Lucie County Division of Disease Control and Health Protection Bureau of Environmental Health 5150 NW Milner Drive Port Sf ,Lucie, FL 34983 PHONE: 7721873-4931 • FAX: 772/595-1306 FlorldaHealth.gov, Accredited Health.Department Public Health Accreditation Board SEI STATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT, REPAIR, MODIFY, ORABANDON A WELL c4>il>Lsr w, ❑Northwest •: y¢ o,'sn "� PLEASE FIELDS ❑Northwest (*Denotes Required Fields Where Appl icable) ❑ St, Johns River 3 The vra(ern dconbecforle respott appl/or camo ilia g. ❑South Florida this/ormandlorwardingUiepermifappliceGonfofho .e f ❑Suwannee -.River appropriate delegated authority whereappllpble. . 4 P ❑DEP 0DelegatedAuthority '.(if Applirable) Unique ID Stipulations Required (SeeAheched) Quad No. . .Delineation No. 'Well"Lccalion : Add�ess,;Rokd Neme: orNumber, City 3.'Parcel ID No. (PIN) or Altemate Key (Circle One) �1 +n I Lot Block Unit 4. °"" • t '�' V"" �J6 'eckif62-524: Yes Township 'Range Subdiv `hiLan — Wet rWell.Con ctor II 'Clcense um er elephonnee (Number E-mail Address 'Water Well Contractor'sAddress CIcitySta a '�a�7'�a - ZIP, , 7. Type cf work: ,� _%erfconstruction 'Repair _Modification _Abandonment 8. NurnberofPropgsedWells- Reasonfornepat,modietavon,orAbandonna I 9. Sp fY Intended Use(s) of Well(s): /A\ I J �[ Domestic Landscape lnigaton _Agricultural Irrigation. _Site Investigation Lr-+.1 LI- Bottled Water Supply _Recreation Area Irrigation _Livestock _Monitoring. I Nursery Irrigation _Test _Public Water Supply (LimitedUseIDDH) CommerciaUlndustdal _Earth: Coupled Geothermal NOV 9 2019 Public Water Supply (Community or Non-Community/DEB) — _Golf Course Irrigation HVAC Supply _Class.I Injection _HVAC Return Class V Injection: _Recharge _Commercialllnduslrial Disposal _Aquifer Storage and Recovery _Drainage DOH in St Curie COUI Remedlation: _Recovery _AirSparge Other (Describe) VIRONME0lFAil>fIEA Other (Destribo) (Note: Not au Wes ofwolis are pemtilted by a given partnittIng outhoniy) 1 O.*Distancefrom Septic System If's200 ft. 11-Facility Description P t5 Cd 4A a 2- 12. Estimated Start Date 13.'Estimated Well Depth 1'f,0 ft. 'Estimated Casing,Depth (%O ft. 'Primary Casing Diameter �in. Open Hole: From_Tc ft. 14. Estimated Screen Interval: From t�To (Z O.ft. '5.'PrlmaryCasing Material: - ____,Black Steel _Galvanized _ VC _Stainless Steel _NotCased Other. 6. Sec'ondary.Casing:, —Telescope Casing _ Liner _ Surface Casing Diameter In. 7, Secondary Casing Material: Black Steel _Galvanized _PVC _Stainless Steel _Other 8.'Method of Construction, Repair, orAbandonment: .Auger Cable Tool _Jetted ' : f otary :_Sonic I .Combination (Two or.More Methods) _Hand Driven (Well Point, Sand Point) _Hydraulic Point (Direct Push) Horizontal Drilling _Plugged by Approved Method _Other(Dosenbel 9. Proposed GroutingInterval;forthe Primary, Secondary, and Additional Casing: I 20. Indicate total number of existing wells on site . List numberofexistingunusedwells on site. d. 21'Isthfswelloranyexisting, well orwaterwilhdmwalonthe owner's contiguous property covered underaConsumptive/Water Use Permit (cUPAN,UP) orCUPIWUPApplication? _YesJNo If yes, complete 'thefollowing:CUP/WUP.No. District Well ID No. 22. Let ILIde Longitude .. 23. Datla Obtained From: _GPS _Map _Survey Datum: NAD 27 _NAD 83 WG$ 84 I hem*lby.4 tort l"osotb tba.pp3 iom.,.rTille4e;GmdaANNnisaeNv nadgeM Mvtuwabr I-a4*,stlam Na oxrctol_wpmpeM. alai Np w fiollerr pmvwto is..ts,am tai lvmmva,o or ub pormll orvmrmblm0.". pam anadda,lu.va hm eCoen are obtaNed pMrloammanconwntof wall mspllt vuMu Chopty 373. ileddu SUMm,ton,ahlaL, or pros" pM,dat M xK: a a I NrMy Vol lmn mn,tna.l. ItiMdi xnhautabmimmaLbn pmvkMMlCII app:bieonbpaa,dlvoMlFallwL obViin aro p3eN In ma pemn;tlml ale CdpmalbnpmNdedbacanale, and tnotlhvvv brommdlltvawmr NtMk nacvewryvgvoval GpmaNar roes, iatalate,aloos- S, a opp'laabla. I Wrep to pwbdtiwn mspwM .sfttlw eCwa. OmiernwN+baOOMny petsomtldetl+NTfeor MJ[ga1WPUWtIIYnvgs9 mmpivibn;mpo b psbdxilhin30 after m alu.awluaan mpa'v, ndemoam,ar banvc0 ub duNgthv m,xwebn, terulr. i,odfioaam;aoWndoturcN o`a ttadbytCepvmtlL pCwdmmjn byP _ wCkMm.finC 'Sj na o _ onbactor - ... 'License No. - . 'Sign of Ovmer orAg , _ Da re Approval Granted By Issue Dale I I I Expiration Dales q ydrologist'Appioval - }' Inia19 - Fee Received S Receipt No. - Check No:. - THIS PERMITISNOT VALID :UNTILPROPERLY SIGNED BYANAUTHORIZED OFFICER OR REPRESENTATIVEOF THE WMD OR. DELEGATEDAUTHORITIt THE PERMITSHALL'BE AVAILABLE ATTHEWELL SITE. DURING ALL CONSTRUCTION. REPAIR,MODIFICATION, ORABANDONMENTACTIVITIES. DEPFdrm:62-532.400(1) Inmrporatedirir62532.400(1),,FA:C. Effective pate: October 7,2010 Paget oft rS75.00' EXISTING 7WELL 3:35' 3.36'I FND % IRC2 22.$'2525" E " 300.00' LS # 4363 x— —x—k— o — x —,x x — x x 5, ARM FE�VCEx ^ � $.0 ! —�F PROPOSED _ � DRAINRELD Q SET % IRC \2 PROPOSED tl +=350SQ FT PROPOSED �y LB # 7903 WELL ZGREEN 23,8x \ t0 25.0• AREA e , - I o 0 0 151.62' 25� � a 00 30.04' 35.00' 34.00' O x- U, O a2oo Q Q W �,� oo• PROPOSED to O Q V COVERED y i cWi1 Q j A L L¢ EXISTING a �. W N c PORCH o OOma P' l HOUSE o a�Q� n o 21,9 x v aOt~i�Q2W c VAC / .�OWtq�� 50.8' 13.3' W LL PROPOSEDtzoo 00' �'30.56' 4 E 1141.85' COVERED -vuK-oo' 24.0 20.8 2 O 35;00' _ 23 ROPOSED O- 18'X22 23,5 X CONCRETE 0 25.0 . T N' PROPOSED 16' of SHELL DRIVE I 23.8 ,5 / �23.2 FND%IR NO ID 75.00' m E _-® 22.9 EXISTING FND%IR NO ID 22.0 x 24.8