HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
"CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ X,]New System [ ]Existing System [ ]Holding Tank
[ ]Repair [ ]Abandonment [ ]Temporary
APPLICANT: Abercrombie/Suntree Homes AGENT
PROPERTY STREET ADDRESS: Emerson Ave Fort Pierce FL 34951
LOT: BLOCK:
PROPERTY ID #: 10-34S-39E-
CENTRAX #: 56-SF-09079
DATE PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 06-0485--N
Innovative Other
SCANNED
SUBDIVISION:
[Section/Township/Range/Parcel No.]
[OR TAX ID NUMBER]
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 �ITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1350 ]Gallons SEPTIC TANK
A [ 0 ]Gallons
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0
D
R
A
I
N
F
I
E
L
D
[ 923 ]SQUARE FEET
[ 0 ]SQUARE FEET
TYPE SYSTEM: [
CONFIGURATION: [
MULTI-CHAMBERED/IN SERIES: [Y ]
MULTI-CHAMBERED/IN SERIES: [Y ]
] GALLONS @ [0 ] DOSES P1ERR.{(2-14 HRjS/) /j# PUMPS( 0 ]
PRIMARY DRAINFIELD SYSTEM (0a ✓x. 5 V I I [/ V V � yl
SYSTEM
N ]STANDARD [ N ]FILLED [ Y ]MOUND [ ]
N ]TRENCH [ Y ]BED [ N ]
LOCATION TO BENCHMARK: Nail In Edoe of Emerson Ave. Near S. P/L (Labeled "Blade")
ELEVATION OF PROPOSED SYSTEM SITE [ ] [ INCHES ] [ BELOW] BENCHMARK/REFERENCE POINT
BOTTOMi OF DRAINFIELD TO BE [ 12.0 ] [ INCHES ] [ BELOW] BENCHMARK/REFERENCE POINT
FILL REQUIRED:[ 22.0 ]INCHES EXCAVATION REQUIRED: [ 96.0 ] INCHES
The licensed contractor installing the system is responsible for installing the
category of tank in accordance with s. 64E-6.013(3)(P), FAC.
Home stvbout invert to be level with benchmark. *Elevation revised 3/14/2007*
Excavate 641xl7'x7' deep.
SPECIFICTIONS BY: POLISSKY, JODI
APPROVEDjBY: Polissky, Jodi
DATE ISSIUED: 11/17/06
TITLE:
TITLE: Environmental Spec St. Lucie CHO
EXPIRATION DATE: 5/17/08
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) fostds_co s_4016-11 Page 1 of 2
d qnE 4_
_ _fst, STATE OF FLORIDA
°'� " DEPARTMENT OF HEALTH
',p ONSITE SEWAGE DISPOSAL SYSTEM
°ate ��' SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Abercrombie/Suntree Homes
AGENT: WILLIAM BENNETT
LOT: BLOCK: SUBDIVISION:
CENTRAX #: 56-SF-09079
OSTDSNBR : 06-0485-N
ID#: 10-34S-39E-
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,
MUST PROVTDF, REG STRATTON NUMBER AND SIGN AND S.AL EACH PAGE
OR OTHER QUALIFIED PERSON. ENGINEER'S
OF S BMTTTAL. COMPLETE A• TTEMS.
PROPERTY SIZE CONFORMS TO SITE
PLAN: [X]YES [ ]NO
NET
USABLE AREA AVAILABLE: 6.11 ACRES
TOTAL ESTIMATED SEWAGE FLOW:
500 GALLONS
PER DAY
[64E-6, TABLE 11
AUTHORIZED SEWAGE FLOW:
9165 GALLONS
PER DAY
[1500GPD/ACRE OR 2500GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE:
2000 SQFT
UNOBSTRUCTED AREA REQUIRED: 1538 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Nail In Edge of Emerson Ave. Near S. P/L (Labeled
ELEVATION OFF PROPOSED SYSTEM SITE IS 16.00 [ INCHES ] [ BELOW ]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: 7+ FT PROPERTY LINES: 15+ 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
inyR-R/R-R VW Canrl
l nVR-7/fi-VW Canei
i nvR-F/i -r_v rl a=
inyg-%/i-rV RoPnaal
USDA SOIL'SERIES: Unknown
Depth
n to i R
1R to Ra
7a to Rq
�q to 79
to
to
to
to
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture
Depth
to
to
to
to
10YR-4/1-D GY Fins Land
n to iR
i nyR-5/9-r RN Fino Cann
iR to 4n
i nyR-,;Ir-V RN Cann
an to dd
1nyR-q/1-ry rlav
44 to dR
USDA SOIL SERIES: Unknown
OBSERVED WATER TABLE: 44.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [ PERCHED ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:20.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:Fine Sand/0.65 DEPTH OF EXCAVATION:96.0 INCHES
DRAINFIELDICONFIGURATION: [ ]TRENCH [ X ]BED [ )OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
Estimated WSWT determined from USDA Soil Conservation Svc soil survey of SLC 6 existing
BDF elevations of surrounding properties.
SITE EVALUATED BY: JODI POLISSKY
DH 4015, 03/P7 (Obsoletes previous editions which may not be used)
(Stock Numbe�: 5744-003-4015-1) [ostds_eval_4015-3]
DATE: 11/7/06
Page 3 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
:ONSTRUCTIO PERMIT FOR:
[ X ]New By tem [ ]Existing System [
[ ]Repair [ ]Abandonment [
SCANNED
BY
St. LUCi@'%#011*
]Holding Tank [
]Temporary [
CENTRAX #: 56-SF-09079
DATE PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 06-0485--N
APPLICANT: Abercrombie/Suntree Homes AGENT:WILLIAM BENNETT
PROPERTY STREET ADDRESS: Emerson Ave Fort Pierce FL 34951
Innovative Other
LOT: BLOCK: SUBDIVISION:
[Section/Township/Range/Parcel No.]
PROPERTY ID;#: 10-34S-39E- [OR TAX ID NUMBER]
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 [ 1350 ]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 ] GALLONS @ [0 ] DOSES 24HR # [
0 ]
�PPEERj-�
D [ 923 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM-0a l X I 5l
R [ 0 ]SQUARE FEET
SYSTEM �'--CCClll���//////��I��I
A TYPE SYSTEM: [ N ]STANDARD
[ N ]FILLED [ Y ]MOUND [ N ]
I CONFIGURATION: [ N ]TRENCH
[ Y ]BED [ N ]
N
F LOCATION TO BENCHMARK: Nail In Edge
of Emerson Ave. Near S. P/L (Labeled "Blade")
I ELEVATION OF PROPOSED SYSTEM SITE [
] [ INCHES ] [ ABOVE ] BENCHMARK/REFERENCE
POINT
E BOTTOM OF DRAINFIELD TO BE [
26.0 ] [ INCHES ] [ ABOVE ] BENCHMARK/REFERENCE
POINT
L
D FILL REQUIRED:[ 32.0 ]INCHES EXCAVATION REQUIRED: [ 96.0 ] INCHES
OTHER REMARKS:
The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with a. 64E-6.013(3)(f), FAC.
Home stubout invert to be 38 inches above benchmark.
Excavate 641'xl7'x7' deep.
SPECIFICATIONS BY: POLISSKY, JODI
APPROVED BY: Polissky, Jodi
TITLE:
TITLE: Environmental Spec St. Lucie CHD
DATE ISSUED: 11/17/06
DH 4016, 03/97 (obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) [..td. cane 4016-11
EXPIRATION DATE: 5/17/08
Paqe 1 of 2
[ X ]
[ l
STATE OF OBR PERMIT
DEPARTMENTTFLORIDA
OFF HEALTH h DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL ' FEE PAID:
SYSTEM RECEIPT #:
APPLICATION FOR CONSTRUCTION PERMIT
FOR:
New System
Repair
APPLICANT: SUNTREE
[ ] Existing System [ ] Holding Tank
[ ] Abandonment [ ] Temporary
[ ] Innovative
r
AGENT: William B. Bennett, PSM TELEPHONE
MAILING ADDRESS: 439 SE Port St. Lucie Blvd, Unit 107, Port St. Lucie Florida 34984
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 (D44/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: BLOCK: SUBDIVISION:
PROPERTY ID # S10/T34S/R39E [Section/Township/Range/Parcel No.]
DATE
PLATTED: UNPLATTED
ZONING:
PROPERTY SIZE: 6.11 ACRES 266,219 [Sgft/24490] PROPERTY WATER SUPPLY: [X] PRIVATE [ ] PUBLIC
PROPERTY STREET ADDRESS: VACANT LAND ON EMERSON AVENUE
DIRECTIONS TO PROPERTY:US-1 NqORTW TO INDR 0 ROAD W ST. TO
FMERSO AVID. NO H
�X
/ri
O'
BUILDING
NFORMATION `-' 1 RESI
ITT - ._
1 CO mxr AT-
-
Unit
Type of No. of
isuilding
Commercial/IMStiCIItavuai System Design
NO
Establishment Bedrooms
Area Sqft
_Table 1, Chapter
64E-6, FAC
1
2�/�Iavr/�y�i
Residential 5
vUc�3�lC��,Dlowh
3
4
Garbage Grinders/Disposals
[ X ] Spas
/ Hot Tubs
[
Ultra -low Volume Flush Toilets
] O er
(Specify)
] Floor/Equipment Drains
APPLICANT'S SIGNATURE: _ DATE: 09/23/06
e
STATE OF FLORIDA CENTRAX #: 56-SF-09079
DEPARTMENT OF HEALTH OSTDSNBR : 06-0485-N
ONSITE SEWAGE DISPOSAL SYSTEM
w .." SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Abercrombie/Suntree Homes
AGENT: WILIIAM BENNETT
LOT: I BLOCK: SUBDIVISION: ID#: 10-34S-39E-
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 6.11 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 500 GALLONS PER DAY [64E-6, TABLE 11
AUTHORIZED SEWAGE FLOW: 9165 GALLONS PER DAY [1500GPD/ACRE OR 2500GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: • 2000 SQFT UNOBSTRUCTED AREA REQUIRED: 1538 SQFT
$ENCHMARK/REFERENCE POINT LOCATION: Nail In Edge of Emerson Ave. Near S. P/L (Labeled
ELEVATION OF PROPOSED SYSTEM SITE IS 12.00 [ 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: 7+ FT PROPERTY LINES: 15+ 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
10YR-9/8-R'YW Rand n to 1A
lnvg-7/6-Yw Rand 1A to 'Al
1nVR-6/1_ry Rwfumal 99 to 72
to
to
to
to
USDA SOIL SERIES: Unknown
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture
Depth
1nVR-9/9-A YW Rand
n to 1A
10YR-7/f:-VW Rand
1A to AF
1nVR-f,/1-ry rlay
if. to 67
lnVR-A/1-rY Rafnnal
42 to 77
to
to
to
to
USDA SOIL SERIES: Unknown
OBSERVED WATER TABLE: 30.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [PERCHED ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:10.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL TEXTURE/,LOADING RATE FOR SYSTEM SIZING:Fine Sand/0.65 DEPTH OF EXCAVATION:96.0 INCHES
DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
Estimated WSWT determined from USDA Soil Conservation Svc soil survey of SLC & existing
BDF elevations of surrounding properties.
SITE EVALUATED BY: JODI POLISSKY
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-003-4015-1) [ostds eval 4015-3]
DATE: 11/7/06
Page 3 of 3
0,�6t"E STATE OF FLORIDA PERMIT #.
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: SUNTREE HOMES AGENT: William B. Bennett PSM
LOT: i BLOCK: SUBDIVISION: UNPLATTED
PROPERTY ID #: S10/T34S/R99E [Section/Township/Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTEMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINNEER;
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS
PROPERTY SIZE CONFORMS TO SITE PLAN: [ X ] YES [ ] NO NET USABLE AREA AVAILABLE: 6.11 ACRE
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE23
AUTHORIZED SEWAGE FLAW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 900 +\- SQFT UNOBSTRUCTED AREA REQUIRED: SQF
BENCHMARK/REFERENCE POINT LOCATION: PK Nail at centerline of road S East lot line extended
ELEVATION OF PROPOSED SYSTEM SITE IS 13 [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POIP
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE
SURFACE WATER: 100 FT DITCHES/SWALES: 15 FT NORMALLY WET? [ ] YES [ X ] NO
WELLS: PUBLIC: 200 FT LIMITED USE: 100 FT PRIVATE: 75 FT NON -POTABLE: 50 1
BUILDING FOUNDATIONS: 7 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 100 1
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ X ] NO 100 YEAR FLOODING? [ ] YES [X] N
100 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NG`
SOIL PROFILE INFORMATION SITE 1
MUNSELL #/COLOR TEXTURE
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA,SOIL 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 / APPARE]
ESTIMATED WET SEASON WATER TABLE
ELEVATION:
INCHES
[ABOVE
/ BELOW] EXISTING GR
HIGH WATER TABLE VEGETATION:
[ ]
YES [ ] NO
MOTTLING: [
] YES
[ ] NO DEPTH: INC
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ X ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
INC.
SITE EVALUATED BY: �� DATE: 09/23/06
m
STATE OF FLORIDA PER?IIT APPLICATION TO CONSTRUCT,
(REPAIR, MODIFY, OR ABANDON A WELL
D Southwest
❑ Northwest THIS FORM MUS7BEFILLED our COMPLETELY.
❑ St. Johns River The wafer weft contrsebris rvspansibfe frrcmpletlng tltiy'
0 South Florida loan andfarwaMln9 tlrepe.•mn /a Ilia eppApdetederegafod
0 Suwanriee.River munrywhsra applldebre.
CHECK BOX FOR APPROPRIATE DISTRICT
J. %01rJ ^
-
2- AIkUk! Erne_r,0,(Y 4%,e 1l1Q_
3. 6C_ wLii� lJr���t.1r
Ng•660.i ?• 2/6
Peradtstipul;uio oiled
a 524 well O
car
" Appticadm \o.
77d-) 5g.S-5331
Tdohow Numb,,
N 8 1 1 �J t1.] T'•ZOi� i"�/�. 4, Z�I '/.af'�!3 '/.at Section (IVY. ....y.
Address
,l+mxy Ricca
�l}• LVCL� �L Tmmshl
3�1953 ttnd-bwylanGad)
5.. p _ Range E
city SLqtd Zip
a. 5�•. 1_L)c�� � Q�r�� (310-ul.a-cc�o i-oov-•5
GVunty Subdivision Name Lot IBtcdc — (Unit
7. Number of proposed wells I_ Check the use df well: ✓Domestic (Res. Home)
_ Inigaden (Business) _Public Water Supply mustness) List Other
Distance from septic system rS R Distance from foundation
Estimated start of construction date
S. Application for. _y New ConsWction RepaiaModify
Abandonment (Reason forabandonment 1
9. EsUrnatScreened: Well m Casing Depth
Screen Diameter
_�e1�_�Castnq Men I C IPv
Casing Diameter f _ Seal matedly L
t0.lfapplicahte; Proposed From �•1 ,(oSealMatartal vu
Grouting Interval From . to Seal Material
From _ to-- Seal Material
11. Telescope Casing or liner . (check one) Diameter
BIk-SteelIGalvarirzsd/PVC other(spedfy):
12. Methed of Construction: _Ra" ble r.l _CaMwmllpn
_Auger _Other
13. Indfcate total No. of welts an site -a. List No. of unused welts on site
14, Is this wen or any otharwal orwaterwithdrawal anthe owner's contiguous fop covered under
mlfl
a CpnsampUveM'alor Use Fe(CUPMUP) or CUPIWUPApplIcatlan7 NI _;Yes
fllyes, romplafa the raffawfnq) CUPNPUP No. _
1s.
oistilct well ID No.
Latitude Longitude
Data Obtained ham GPS—ormap_ orsurvay_ (map datum MAD 27_,NAD 83 1
west
n
_Monitor _ rrigstlon (Residential)
and
Fast
Approval Granted By: Issue Date:
�ydrotogistApprovel
Owner Number. w
Fee Recaiv d: Receipt No.: Check No:
Inspected by: Date:
THIS PERMIT NOT VALID UNTIL. PROPERLY SIGNED BYAN ALfTHORIZED OFFICER ORRS=RESEYLATNEOFTHEWMD. r SHALLSE AVAnA2LE ATTtir WELL
SITE OURING ALL DRILLING OPERATIONS, TMa permlt is y26d ter ad days."" dare of Issue.
PUM 0123