HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CORSTRQCTION INSPECTION AND FINAL APPROVAL,
APPLICANT: GEM Builders. Inc
V /'ful-D149-9
I&PPLicATion #IAP1420499
ftm= #.58-SF-1999435
DOCUMENT #:.FI13876'93
DATE PAID,06/24/2019
rVIN
ZZANED FEE PAII)'Q'?V-
BY RECEIPT #56-PID-3997509
St. Ludprnnnty
AGENT.,.
'Gem Builders, Inc,
- -
PROPERTY' ADDRESS: 1416 Lone Pine Dr Fcrt.Pierce,'FL 34982
LOT: 11
BLOCK,
Lone Pine jD#_ 340040S-0016-006-9
CHECKED rxi ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE,ANU MUST —BE CORRECTED.
TANK INSTALLATION
SETBACKS
[011
TANK SIZE ril 1090.00 [21
[9713
SURFACE MWER FT
I
I
EOZI
TANK MATERIAL PotyprolaViene
j
j (28]
DITCHES FT
I
I
E031
OUTLET DEVICE
E
r291
PRXtMTE WELLSFT
E
'I
E041
MULTI -CHAMBERED J� N I
f
E101
PUBLIC WELLS VT
f
1
1051
OUTLET FILTER Polylok'PL-68
I
I [Jill
IRRIGATION WELLS 100 FT
E
.3
ED61
LEGEND- 1, 70-148-11DC4 2,
1
1 1321
POTABLE V , A , TER 10 FT
t
1071
WATERTIGHT
'r:§:§!
BUILDING FOUNDAtIdWS FT
1
[081
LEVEL
E
1 [341
PROPERTY LINES 5 FT.
1
1,091
DEPTH'.TOLID--.
r351,
OTHER FT
DRAMMIELD INSTALLATION
FILLED / MOUND SYSTEM:
I
tIO)
AREA Ell - 679.2 r2-I- sQrz
[
I r36-1
DiRAIWTEILD COVER
E
1
[11-3
DISTRIBUTION BOX'_IM=ER x
[
1 (371
SHOULDERS
NUMBER OF DRAnMINES 1. 7:00 2.
E38f
SLOPES
E,
I
[li]
-DRAINLINE SEPARATION
[39],
STABILIZATION ()3109/2020�
I
E141
DRKINLINE SLOPE
C.
1
[153
DEPTH OF COVER
ADDITIONAL INFORMATI014
r
1
1161
ELEVATION E�i BELOW IBM: 9;00
C
1 140.3
UNOBSTRUCTED AREA
E
1
[17]
SYSTEM LOCATION
L
I E411
STOR14WATER RUNOFF
I
Elel
DOSING PUMPS
(
) t4211
ALARM
I
[1 91
AGGREGATE OIZE
E
3 [43]
MAINTERANCE, AGREEMENT
1
1201
AGGREGATE EXCESSIVE PINES
E
1 [441
BUILDING AREA
1
E211
.AGGREGATE:.DEPTH -
C
1 1453
LOCATION CONFORMS WITH SITE_PLAN
FILL ixcAvAmioa MATERIAL
I'
I C 1 463
XIIIA3Y SITE GRADING
C
1
[221
FILL AMOUNT
E
1 (471
CONTRACTOR MICHAEL W STUHR (ASHT0
1 [481
OTHER If4FILTkAfdPQuick4.PIus Ewe Lp
r
1
1231
Fl=, TEXTURE
[
]
[241
EXCAVATION DEPTH
ABANDONMENT
1
[is]
AREA REPLACED
1 [491
TANK PUMPED
I
E261
REPLACEMENT MATERIAL
E
1 (501
TANK CRUSHED & FILLED
Comments: Comments are; on page 2.
St.,Lufcie CED DATE: 0111119020
CONSTRUCTION
1[ APPROVED
Eft_Vjf.rowqntaISpqc011st1
I ngtasfi (EWRONMENrAL HEALTH)
FINAL SYSTEM
_ZA
E DISAPPROVED' I- 4_&ii==n:1_
St. Luc[i6 CHD DATE'.: 03109/2020
- - Efivirommental Speciallst,11
13
j jngraaa,(FRV1PQONMENTALHEALTH)
(Expla�tidfi',of Violations an, following paga)
7
DH
4016,
108109 (Obs6letea all previous editions Which may, not
be used)
Incorporated:
64E-6_003, PAC,
Page 2 of 3
EH Database v 1.0.1 API4Y6499
EID1969436
The system is: stied for'3bedrooms .wftb.a.maximum occup4WofSper sorts (Z. per,` be(ftqorn ,), for a total estimated -flow of 400
$T,ftr and 4YQ+$A Lang B EP OP installed,
iMon for, Irrfodtlorl Weft Inspoctlorildetback, MO
C
ok to cover. 'Contractor .notified by phojid., Needs final
5�
D-Ij 4011&, 00/Qg (cibsolet9s; a3a.,pravloust ed:Ltions which may riot be used)•
XnCOXPOr,%ted; 6413-6,003, MC- fage 2 q:F 3
EH Database v 1Ali AP1420499 EID-190914315
G�
f
STATE OF FLORIDA
�) DEPARTMENT OF HEALTH
p ONSIYSTEMTE SEWAGE TREA�NT AND DISPOSAL
S
APPLICATIpN A?P-LICATION FOR: FOR CONSTRUCTION PERMIT
C New System
C ] Repair
APPLICANT.9
AGENT:X
MAILING ADDRESS: X
C l Existing System
C 7 Abandonment C 7 Holding Tank
C 7 Temporary
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
C ] Innovative
C ]
TELEPHONE:N ' By '
�9---H niinf+
TO BE COMP ----- . LETIC BY APPLICANT OR APPLI _
BY A PERSON LICENSED pURSUANT CANT S AUTHORIZED
PLATTEAPPLID
ANT•g RESPONSIBILITYTO 469..05 3 AGENT' SYSTEMS MUST BE CONSTRUCTED
TO PR ( )(m)OR 489.552, FLORIDA STATUTES.
PLATTED (MM/DD/yy) IF RE �''mE. DOCUMENTATION OE THE DATE THE LOT IT IS THE
()UESTING OF
OF STATUTORY WAS CREATED OR
PROPERTY INFORMATION GRANDFATHER PROVISIONS.
LOT: BLOCK:---_----1
SUBDIVISION: S p
PROPERTY ID #;`X_
PLATTED:A 00S
ZONING: I/M OR
PROPERTY SIZE; ff''�� SEQUIVALENT; C y / N l
.ACRES WATER SUPPLY: C Il PRIVATE
23 SEWER AVAILABLE AS PER 381.0065, FSa C Y•/Q
L;R. TY ADDRESS: 1V16, /.._ ., n. .. A ., -a ./' n
DIRECTIONS
TO PROPERTY:
r
BUILDING INFORMATION
Unit Type of
No
1
2
i
3
a
4
PUBLIC Cxl<=2000GPD [ 1>2000GPr
DISTANCE TO SEWER: FT
CX RESIDENTIAL
L 7 COMMERCIAL
No. of Building Comme
Bercial/Institutio
�droo_s pre_a�Sgft Table 1, � System Design
Cha ter 64E-6, FAC
] Floor/E --�_ guipment Drains [ ] Other (specify)
IGNATURE
H 4015, 08/09 (Obsoletes ncorporated 64E-6.001, FACprevious editions w hick
may not be used)'
DATE : x
Page 1 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
LOT: �_ BLOCK:
PROPERTY ID #
SUBDIVISION:
X
PERMIT #.
I Section/Township/Parcel No. or Tax ID Number
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MOST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE. CONFORMS TO SITE PLAN: �(j YES I ] NO NET USABLE AREA AVAILABLE-- d„j O ACRES
TOTAL .EST32fATED SEWAGE FLOW: 30O GALLONS PER DAY [RESIDENCES -TABLE UOTHER-TABLE2 ]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: a /S�Q/FT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/REFERENCE POINT LOCATION:p%jQ�}/'/(�j$�
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHESIPT ] [ABOVE/BLOW] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 0�4 FT DITCHES/SWALES: /7,4. FT NO Y WET? [ ] YES jx] NO
WELLS: PUBLIC: ",QQ _FT LIMITED USE: FT PRIVATE:_ NON -POTABLE: J FT
BUILDING FOUNDATIONS: _FT PROPERTY LINES:-40—FT POTABLE WATER LINES: �FT
SITE SUB.LECT TO FREQUENT FLOODING: [ ] YES 0 NO 10 YEAR FLOODING? [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
MUNSELL #/COLOR TEXTURE
TO
TO
USDA SOIL SERIES:
�U" rlcvr-ilvr 11 ZUMnH.'1'1VLV b1TZ G
MUNSELL #/COLOR TEXTURE '
USDA SOIL SERIES:
TO
TO
TO
TO
TO
TO
TO
OBSERVED SORTER TABLE: INCHES [ABOVE/BELOW 7 EXISTING GRADE. TYPE:( PERCHED /APPARENT ]
ESTIMATED NET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE
HIGH 14ATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING.RATE FOR SYSTEM SIZING• DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATI6N:'-[,.1 TRENCH I ] BED ] ] OTHER .(SPECIFY)
.v
My I
SITE EVALUATED B DATE: c7 Q
DH 4015, 12/11 (OtisolTt�upvP .ious editions Which may not be used) Incorporated: 64E-6.001, FAC dge 3 0:c 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR:
OSTDS New
APPLICANT: (GEM Builders, Inc)
PROPERTY ADDRESS: 1416 Lone Pine Dr Fort Pierce, FL 34982
PERMIT #:56-SF-1969435
APPLICATION #:AP1420499
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1242257
LOT: 11 BLOCK: SUBDIVISION: Lone Pine
PROPERTY ID #: 3409,505-0016-000-9 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF .SECTION
361.0065, 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
T [
1,050 ]
GALLONS / GPD Seotic New
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 [ 500 ] SQUARE FEET
R [ ] SQUARE FEET
A TYPE SYSTEM: [ ]
I CONFIGURATION: [X]
N
F LOCATION OF BENCHMARK:
Drainfield New SYSTEM
N/A SYSTEM
STANDARD [ ] FILLED [X] MOUND
TRENCH [ ] BED [ ]
Site SM E #D of
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED: [19.001
0
T
H
E
R
inted orange triangle on pavement
[ 6.00 ] [ INCHES FT I[ ABOVE BELOW BENCEMARK/REFERENCE POINT
[ 5.00 ][ INCHES FT ][ABOVE HELOW BENCHMARK/REFERENCE POINT
system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
gpd.
SPECIFICATIONS BY: Hunter A Collier TITLE' Environmental Specialist I
APPROVED BY:tom TITLE: Environmental Specialist I St. Lucie CEO
8unler�i llier '-
DATE ISSUED: 06/27/2019 EXPIRATION DATE: 12/27/2020
DR 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1420499 SE1191567
i
is
4 STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PELT
CATI
ON FOR:
CVNJ New System [ ]
[ 7 Repair C 7
APPLICANT:
AGE- NT:X
MAILING ADDRESS.: X
Well N,b .PERMIT NO
DATE PAID
;" -
FEE PAID: G 'JLk2-�I
RECEIPT 4h
System C 7 Holding Tanknt C 7 Innovative
C 7 emporary C 7
TELEPHONE:N
.., uu VVP1L''•ne y'p;U BY APPT.Tl+TTim .. — // -�
- -- �---...T OR APPLICANT'S AUTHORIZE➢ AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSUN-LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCOMCNTATION 9. THE DATE THE LOT WAS
CREATED
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. OR
PROPERTY INFORMATION
LOT: —9— BLOCK; SUBDIVISION:
On, /n 0, "5✓ PLATTED: 0
PROPERTY ID 4k:� .
ZONING:
PROPERTY 9IZE: 0i3 CJACRES WATER SUPPLY:
'C ] MrVATE
IS SEWER AVAILABLE /AS/ P//
PER 381.0065, FS? [ y•/Q
-PROPERTY ADDRESS: 1416 [ nn a D11 O IJ.P r-- -r A.
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type 'of
NN O Establishment
1
2 6
i
3
4 i
I/M OR EQUIVALENT: [ Y / N ]
PUBLIC [A]<=2000GPD C 7>2000GPr
DISTANCE TO SEWER: FT
_r
C RESIDENTIAL C ] COMMERCIAL
No. of Building Commercial/Ips
Bedrooms titutional System Design
AAreeaSft
lgTable 1, Chapter 64E-6 PAC
I Floor/Equipmen r ] Other (Specify)
S GNA (//�
DATE: l7
D r;soletes9 (Obr 1/
Incorporated 64E-6.001, PAC previous edita.ons which may not be used)'
Page 1 of 4
STATE OF FLORIDA APPLICATION # AP1420499
DEPARTMENT OF HEALTH PETIT # 56SF-1969435
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE1191567
SITE EVALUATION AND SYSTEM SPECIFICATION
} APPLICANT: GEM Builders, Inc
CONTRACTOR / AGENT: Gem Builders, Inc
LOT: 11 BLOCK:
SUBDIVISION: Lone Pine ID#: 3409-505-0016-000-9
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: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.38 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 950.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 1000.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE 6.00 I LHLCHES / FT 1 [ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON -POTABLE: 100 FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 15 FT
SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X INO 10 YEAR FLOODING? [ ]YES [X]NO)
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL / NGVD ] SITE ELEVATION: FT I MSL / NGVD
.SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES:Nettles sand
Munsell #/Color Texture
Depth
10YR 4/1
Sand
0 TO 19
1 OYR 512
Sand
19 To 24
1OYR 6/2
Sand
23To.30
10YR3/1
Sand
30To-36
7.5YR 3/3
Sand
36 To 47
1 OYR 4/3
Loamy Sand
47 To 54
10YR 5/2
Loamy Sand
54 To 66
10YR 512
Sand
66 To 72
USDA SOIL SERIES:Nettles send
Munsell#/Color Texture
Depth
1 OYR 411
Sand
0 To 9
10YR 511
Sand
9 To 18
10YR 6N
Sand
18 To 33
10YR 3/1
Sand
33 To 39
7.5YR 313
Sand
39 To 42
1 OYR 4/3
Sand
42 To 47
10YR 4/3
Sandy Loam
47 To 59
IOYR 413
Sand
59 TO 66
1 OYR 512
Sand
66 To 72
OBSERVED WATER TABLE: 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 [X INo MOTTLING: [X]YES [ ]NO DEPTH: 23.00 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Sand/0.60 DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: I ] TRENCH I ] BED [ ] OTHER (SPECIFY)
r REMARKS/ADDITIONAL CRITERIA
IWSWi determined using USDA WSS and sail borings. 10YR 612 stripping In 10YR 512 matrix a 10% with diffuse boundaries starting
at 23" In 5B1. SB1 6" below SM. 5132 4" below SM.
SITE EVALUATED BY:
Collier, Hunter (Title: Environmental Specialist 1) (Florida Department of Health in St
DH 4015, 08/09 (Obaoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
DATE: 06/26/2019
Page 3 of 4
AP1420499 EID1969435 v 1.0.2
L�
Inicvwtrrrrvl/adg!aororli,o4amFo r,rmpyi(p/Intl.
ihsfwmu�tgrNnMnad�e yrmcla{.•yJca-icon rtt ry_o `atryfrtiyrlvr<• deMgaredcuihor.'iyp:hvei�yppcable
.. Ion or Lend i .To �f • LQ i �j _ " Lot i5tock U t.
5. n 8�9e/jCou' ,iry C b slo Chao 11`62.524)J Yes 1
al at CD r• t r �� i.11icStl S
nse Number a phone N apbe
'Water we I Can ors U E-mail dress
•Z. 'Type of Work: - coon s - ..
Ccnst Repair El ModlficatlonO Abandonment city - State
8 'NUmbarotProp se Welts ZIP
9. 'SPecifyIntendedUse(s)of V•%11{s): •RedsonrarRe Q
Domestic. Landsdapebrigatlon '
Bolded Water Suppty Recreation Ag{IcuguralIrrigation ® Slte Investigations G qp�t Public Water Su Area Irrigation ®• Livestock Public Vyater Suppty (Umlted Use/DOH} Mpnitoring 1
(� PpN (COmmuNl or Non-Ciijrn 1pEp Nursery Intgagpn Test
Class I Injection - y l ) Commercial/lndustriat� J� 27 2019
Earth -Coupled - `\
Golf Coarse Intgalion HVAC Supply p
Cass V Injection>❑ Recharge [f Commerctalgndustral Disposal .0
4ememaGon:O ry AlrS ar - HVAC Rate
Recove - .[] Aq"ifer Storage anLlRecovery
:1 Olher ioagmtri • ❑ P 8e . [] Other- loe,cnoeT,. - _
D •Distance fmm.Sepac S tem if 5200 N, only
i 9 F: Faurllly DescripllOn T U
3.'Esdmated Well Depth fL' •Eslimated Castns papth . n�12. Estimated
4. Estimated Screen Interval: From !�yyvy-�, �tt. PrmaryCaslrlg Diameter Start Date
.1sa1Tog;. I OpenHola;. Fromo
5 Pdmary Casing Matefie Black Steel Ga'--R
lvanized pVC `
Not Cased Other. Stainless Sleet
i:,$econdaryCasing: TelescopeCasirg Liner Surface -Casing Diameter- . secondary Casing Material: Black Steel - - In.
Gafyan¢ad PVC Stainless Steel. "
Melbcilat Construction, IT Repair, Or Abandonment: Auger Cable Tool Jetted. Rote? Sonic
Combinahon {Two of More Methods) Hard DrVan{{Well Paint, Sand Point) 'Hydr IirPai Direct Push)
Hodzontei Drilling Plu Plugged 6 -
Proposed Gr G 1 ri 9 Approved Method Other (ocu:,co_t
From�TO larva f the Primary, 5econdary,$nd Add' aF$ast -
.From Seal Material (. Sent
TO e- t Cemen Other
Frain SeslMaterial{ Bentonite as amenI Other
To __ Sea,Materiaf{ 8entanite Nest Cement 1
Fro m .To Seal Material;{ Sentonite Neat Cement Other={
IcatetbtalnumberorexlsOngwelisonshe - Other j
— - Ustnumberofexistm—r
Or.CUP�P any- v ell or water With g unused wells on slle;_ _
APAIIcatlon7 Yae jai O fhe Owner's continuous
23. Data Obtained From;
W'L.,r,,."iYbuxlescroq+rar em.,,,r,w, PS .: Map Survey
==-- D`83 _._WGS 84..
Received S _ _ - - - Issue Date WI i- 1111 Explraden Oete 1. ai 70 - -
- - Recolpt No._ - - Hydrologial Approval
PERMIT IS NOT VALID UNTIL PROPERLY BY AN - - Check No. u�.y
NITSHALL 6EAVAILABLP ATiuo:..T.. _._ _ - AUTHORIZEO.OFFICER OR REPRES - -
:ING ALL CONSTRUCTION. REPAIR MODIFiCAT1pN14pt aTgrr� OOROELEQ4TEDAUTHORITY. THE..