HomeMy WebLinkAboutD.O.H. PAPPERWORKSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM SCANNED
BY
St. Lucie County
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Karl & Laurie Showen
PROPERTY ADDRESS: TBD SIIVer Oak Df Port -Saint
IV) n Ulpa
pEHMIT #: 56-SF-1 868942
APPLICATION #:AP1358917
DATE PAID:
PEE PAID:
RECEIPT #:
DOCUMENT #: PR1140084
FILE COPY
34952 -
LOT: 3 BLOCK: SUBDIVISION: LIII Estates
PROPERTY ID #: 3423-700-0004-000-5 - [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[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
T [
900 ] GALLONS / GPD Septic new
CAPACITY
A [
] GALLONS / GPD N/A
CAPACITY
N I
] GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [
] GALLONS DOSING TANK CAPACITY [
]GALLONS @[ ]DOSES PER 24 ERS #Pumps [
D [ 500 ] SQUARE FEET Drainfield new SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [X] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: Site BM Nall in E side of Silver Oak near center of property
I ELEVATION OF PROPOSED SYSTEM SITE [ 17.0031 INCHE9 FT ][ABOVE HELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 5.00 ][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
t7
O
T
H
E
R
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 II
APPROVED BY: TLE: Environmental Specialist II St. Lucie CHD
Brian J Ingram
DATE ISSUED: 08/17/2018 EXPIRATION DATE: 02/17/2020
DR 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 2.1.4 AP1358917
SE1090120
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 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
HEALTH 5150 NW Milner Dr PortSaint Lucie,
FL 34983
PAYING ON: PERMIT* 56-SF-1868942 e11-oocu:56-BID-3889669 CONSTRUCTION APPLICATIONM AP1358917
RECEIVED FROM: Kamer Survevina. Inc AMOUNT
PAID:
$ 515.00
PAYMENT FORM: CHECK 2012 PAYMENT DATE:
08/08/2018
MAIL TO:—Karl-&-Laurie-Showen
FACILITY NAME:
PROPERTY LOCATION:
TBD Silver Oak or
Port Saint Lucie, FL 34952
Lot: 3 Block:
PropertyID: 3423-700-0004-000-5
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: EvansJS AUDIT CONTROL NO. 96-PID-3640717
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[� ] New System [ ] Existing System [ ] Holding Tank
[ ] Repair [ ] Abandonment [ ] Temporary
PERMIT NO.57'fF-186�yy2
DATE PAID:
FEE PAID: T
RECEIPT
�.W 90A
[ ] Innovative
APPLICANT: Karl & Laurie ShoWen
AGENT: KARNER SURVEYING INC TELEPHONE(772) 288 7206
MAILING ADDRESS: 2740 SW MARTIN DOWNS BLVD #333, PALM CITY, FL 34990
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 APPLICANTS 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: 3 BLOCK: N/A SUBDIVISION: LILI ESTATES PLATTED: May 2005
PROPERTY ID #: 3423-700-0004-000-5 ZO 2/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: 0.63 ACRES WATER SUPPLY: t ATE-aPUBL-:EC 3<=2000GPD [ 3>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / N ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: XXX Silver Oaks Dr.
DIRECTIONS TO PROPERTY: SEE ATTACHED
BUILDING INFORMATION [ J] 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 1725
2
3
4
[ ] Floor/Equipment Drains
SIGNATURE:
[ A ] Other (Specify)
DATE: 7-10-18
DH 4015, 10/97 (Previous Editi64 May Be Used) ONLINE VERSION Page 1 of 4
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
STATE OF FLORIDA APPLICATION # AP1358917
DEPARTMENT OF HEALTH PERMIT # 56-SF-1868942
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
DOCUMENT #SE1090120
SITE EVALUATION AND SYSTEM SPECIFICATION
APPLICANT: Karl & Laurie Showen
CONTRACTOR / AGENT: Kerner Surveying Inc -
LOT: 3 BLOCK:
- - - -svBDzvisioN:L(li Estates ID#: 3423-700-0004-000-5
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: IX]YES [ ]NO NET USABLE AREA AVAILABLE: 0.63 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 )
AUTHORIZED SEWAGE FLOW: 945.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 1040.00 SQFT UNOBSTRUCTED AREA REQUIRED: 750.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION:
Oak near
ELEVATION OF PROPOSED SYSTEM SITE 17.00 [ INCHES / FT ] [ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 100 FT DITCHES/SWALES: 15 FT NORMALLY WET: I ]YES [X)NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 75 FT NON -POTABLE: FT
BUILDING FOUNDATIONS: 5 FT
SITE SUBJECT TO FREQUENT FLOODING?
10 YEAR FLOOD ELEVATION FOR SITE:
von Y.v TA nVMAmTnw RTTA. 1
PROPERTY LINES: 15 FT POTABLE WATER LINES: 45 FT
)YES IX]NO 10 YEAR FLOODING? I ]YES IXINO]
FT [ M.SL / NGVD ] SITE ELEVATION: FT L MSL / NGVD
USDA SOIL SERIES:Waveland fine sand
Munsell #/Color Texture
Depth
1 OYR 4/1
Sand
0 To 15
1 OYR 5/1
Sand
15 To 39
1 OYR 52
Sand
39 To 44
HOLE CAVING
Refusal
44 To 72
•c-nvlfLmrnu eTmr 7
USDA SOIL SERIES:Waveland fine sand
Munsell #/Color Texture
Depth
I OYR 311
Sand
0 To 3
10YR01
Sand
3To17
1 OYR 511
Sand
12 To 39
1 OYR 5/3
Sand
39 To 45
HOLE CAVING
Refusal
45 To 72
OBSERVED WATER TABLE: 26.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE:
ESTIMATED WET SEASON WATER TABLE ELEVATION: 12 INCHES [ ABOVE / BELOW ]
HIGH WATER TABLE VEGETATION: [ ]YES EX ]NO MOTTLING: IX]YES I ]NO
I PERCHED / APPARENT ]
EXISTING GRADE
DEPTH: 12.00 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Replacement 4-S, CS, LCS/0. DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ 1 TRENCH [X] BED [ ] OTHER (SPECIFY)
r- REMARKS/ADDITIONAL CRITERIA
determined using USDA WSS and soll borings.
1 stripping In 10YR4/1 matrix a10% with diffuse boundaries starting at 12" In SB2.
'below 81M. 513217" below SM.
SITE EVALUATED BY:
Ingram, Brian 99e: Environmental Specialist II) (ENVIRONMENTAL HEALTH)
DR 4015, 08109 (absolutes previous editions which may not be used) Incorporated: 64E-6.001, FAC
INCHES
DATE: 08/15/2018
Page 3 of 4
AP1358917 EID1858942 v 1.0.2
STATE OF FLORIDA PERMIT #.56-fT•J�(„��y2
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Karl & Laurie ShoWEn AGENT: KARNER SURVEYING INC
LOT: 3 BLOCK: N/A SUBDIVISION: LILI ESTATES
PROPERTY ID #:3423-700-0004-000-5 [Section/Township/Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTEMENT 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: [J] YES [ ] NO NET USABLE AREA AVAILABLE:0.63 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE2]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE:1015 SOFT UNOBSTRUCTED AREA REQUIRED:750 SOFT
BENCHMARK/REFERENCE POINT LOCATION: Set Mag Nail/Disk at East E/P Silver Oak Dr.E1.101.10 NAVD
ELEVATION OF PROPOSED SYSTEM SITE IS 1.25 [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 75, FT DITCHES/SWALES: 15' FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC:N/A FT LIMITED USE: FT PRIVATE: 75+ FT NON -POTABLE: 50 FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 10 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [�] NO 10 YEAR FLOODING? [ ] YES [q] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
TEXTURE
USDA SOIL SERIES:
TO
TO
mn
TO
J1<M61I U14 blTz C
TEXTURE DEPTH
USDA SOIL SERIES:
TO
TO
TO
TO
TO
)BSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE:[PERCHED / APPARENT]
7STIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ABOVE / BELOW] EXISTING GRADE
SIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
TOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:_
)RAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED
M-MRKS/ADDITIONAL CRITERIA:
ITE EVALUATED BY
N 4015, 10196 (Replaces HRS-R Form 4015
31 which may be used)
DEPTH OF EXCAVATION: INCHES
] OTHER (SPECIFY)
DATE:7.10.2018
Page 3 of 4
7STRUCnONS:
Property Card Page 1 of 1
Michelle
Franklin, CFA -- Saint Lucie County Property Appraiser -- All rights reserved.
Property Identification
Site Address: TBD
Parcel ID: 3423-700-0004- Account #: 162967
Sec/rown/Range:
000-5
23/36S/40E
Map ID: 34/23S
Zoning: Use Type: 0000
Jurisdiction: Saint
Lucie
County
Ownership
Legal Description
-- -- —Karl-Showen
- LILI.ESTATES (PB 46-31) LOT 3 (OR 4111-2846: 4128-908)
Laurie Showen
742 NW V iscaya ST
Port St Lucie, FL 34983
Current Values Historical Values 3-year
Just/Market: $12,800
Assessed: $12,800 Year Just/Market Assessed
Exemptions
Taxable
Exemptions: $0
Taxable: $12,800 2017 $12,800 $12,800
$0
$12,800
2016 $13,200 $12,430
$0
$12,430
2015 $11,300 $11,300
$0
$11,300
Sale History
Date
Book/Page Sale Code Deed Grantor
Price
04-27-2018
4128/0908 0130 WD Showen Karl
$100
03-05-2018
4111/2846 0111 QC Gonzalez Emilio
$100
11-01-2013
3591 / 1453 0111 QC Velez Alina
$100
Primary Building Information
Finished Area of this building: 0 SF
Gross Area of this building: 0 SF
Exterior Data
View:
Roof Cover: Roof Structure:
Building Type:
Year Built: N/A
Frame: Grade:
Effective Year: 2014
Primary Wall:
Story Height: No. Units: 0
Secondary Wall:
Interior Data
Bedrooms: 0
A/C %: 0% Electric:
Primary Int Wall:
Full Baths: 0
Heated %: N/A% Heat Type:
Avg Hgt/Floor: 0
Half Baths: 0
Sprinkled %: 0% Heat Fuel:
Primary Floors:
t..I .. Total Areas
Finished/Under Air
0
(SF):
Gross Area (SF):
0
Land Size (acres):
0.63
` Land Size (SF):
27,443
Total Building Count:
1
Special Features and Yard Items
Type Qty Units YearBlt
This information is believed to be correct at this time but it is subject to change and is not warranted.
V Copyright 2018 Saint Lucie County Property Appraiser. All rights reserved.
tins://www.Dasle.orgMCard/ 8/8/2018
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Custom Soil Resource Report 56 -SF- I
St. Lucie County, Florida
50—Waveland and Immokalee fine sands
Map Unit Setting
National map unit symbol., 1jpwd
-- Elevation:-20.to200 feet _
Mean annual precipitation: 49 to 56 inches
Mean annual air temperature: 70 to 77 degrees F
Frost -free period: 350 to 365 days
Farmland classification: Not prime farmland
Map Unit Composition
Waveland and similar soils: 44 percent
Immokalee and similar soils: 44 percent
Minor components: 12 percent
Estimates are based on observations, descriptions, and transacts of the mapunit.
Description of Waveland
Setting
Landform: Flatwoods on marine terraces
Landform position (three-dimensional): Tail
Down -slope shape: Convex
Across -slope shape: Linear
Parent material., Sandy marine deposits
Typical profile
A - 0 to 4 inches: fine sand
Eg - 4 to 32 inches: sand
Bh1- 32 to 40 inches: loamy sand
Bh2 - 40 to 53 inches; sand
Cg1- 53 to 66 inches: sand
Cg2 - 66 to 80 Inches: sand
Properties and qualities
Slope: 0 to 2 percent
Depth to restrictive feature: 31 to 50 inches to ortstein
Natural drainage class: Poorly drained
Runoff class: High
Capacity of the most limiting layer to transmit water (Ksat): Moderately low to
moderately high (0.06 to 0.20 In/hr)
Depth to water table: About 6 to 18 inches
Frequency of flooding: None
Frequency of ponding: None
Salinity, maximum in profile: Nonsaline to very slightly saline (0.0 to 2.0
mmhos/cm)
Sodium adsorption ratio, maximum in profile: 4.0
Available waterstorage in profile: Very low (about 0.8 inches)
Interpretive groups
Land capability classification (irrigated): None specified
Land capability classification (nonirngated): 4w
Hydrologic Soil Group: C/0
tt
10
Custom Soil Resource Report
Forage suitability group: Sandy soils on flats of mesic or hydric lowlands
(G156BC141FL)
Hydric soil rating: No
Description of Immokalee
Setting
Landform: Flatwoods on marine terraces
Landform position (three-dimensionaq: Talf
Down -slope shape: Convex
Across -slope shape: Linear
Parent material: Sandy marine deposits
Typical profile
A - 0 to 6 inches: fine sand
E - 6 to 35 inches: fine sand
Bh - 35 to 54 inches: fine sand
Cg - 54 to 72 inches: fine sand
Properties and qualities
Slope: 0 to 2 percent
Depth to restrictive feature: More than 80 inches
Natural drainage class: Poorly drained
Runoff class: High
Capacity of the most limiting layer to transmit water (Ksat):
high (0.57 to 1.98 in/hr)
Depth to water table: About 6 to 18 inches
Frequency of flooding: None
Frequency of ponding: None
Moderately high to
Salinity, maximum in profile: Nonsaline to very slightly saline (0.0 to 2.0
mmhos/cm)
Sodium adsorption ratio, maximum in profile: 4.0
Available water storage in profile: Low (about 5.3 inches)
Interpretive groups
Land capability classification (irrigated): None specified
Land capability classification (nonirrigated): 4w
Hydrologic Soil Group: B/D
Forage suitability group: Sandy soils on flats of mesic or hydric lowlands
(G156BC141FL)
Hydric soil rating: No
Minor Components
Jonathan
Percent of map unit: 3 percent
Landform: Knolls on marine terraces, ridges on marine terraces
Landform position (three-dimensional): Intertluve
Down -slope shape: Convex
Across -slope shape: Linear
Hydric soil rating: No
Salerno
Percent of map unit., 3 percent
Landform: Flatwoods on marine terraces
Landform position (three-dimensional): Tall
Down -slope shape: Convex
11
SCANNED
BY )
St. Lucie County l �� Oao
STATE OF FLORIDA PERMIT APPLICATION 70 CONSTRUCT;
.. •• REPAIR, MODIFY, OR ABANDON A WELL 59- scq q _
Pormk No
QSD"hwasl PtERSERLLDLRALLAPPLIC4aLEFIELDS FloddsUnipreID
QNORhwBst {'Denotes Required Fields YphuYeAppllcahle) Fe ISdpulatlone Requ'vod (SeeAtletlr
OSt. Johns River
$ ❑South Florida mewamiaenra+hadw-a meroeawefsr + q!lna
OSuwanneeRiver rnN'8; n"°'"^9 an^ee?r'Wronroue s2524,QuadNe__DeS„atooua a QDF3 IagafedsofhHy wnerc eppAcsalq
❑Delegated AUlhodty (If Appilcablo) CUPA" AW1c*son No._�
F��cnor
er, LegalNarna_IfCorporation Address--• qYes
% -1 3 t 5'; 1 ✓c r U e Tj r %' °L. •Slate •ZIP 'Location -Address, MeNumr C.o. lriN) crAlterr121e Key (5;Ie One)o„vr Z3 3G `/D S�LUiit- Lot Block Land Gram "rmmshl
S. 'D > r7-C+ P 'Range (ounty Subd1 sion Check 1152
^Nato, V/e➢Canhaefor lWA -s- 79�-21S-�i(Y1.4 MPUlJ2tI Dr`li`rL �m a•I sane
'Umnse Number telephone Number E magAdtlress v a. P,D, DP1C 5qt} PP
'WaL=r WeH ConCactar's Address Fot•i- P?�_rc.e FL 7�> Or�
7. T e of Work 0i Sfate Zip
YP __ nsWNion Repel, _Moddication ,_Abandonmem p
a,'Number nt Proposed Wells i mresu, rergepyt Ma �n•a, D
9. • Ufy Intended Uses) of Well(s):
omestic Land f
_BCltled Water S scope Imgetbn _Agriwttuml Irrigation _Site InvJlon i WPN _ReaeatianAma Irrigation _Uveslock Monfiaring ) /e
_Public Water Supply(Lfmlted Use/DOH) _Numerylydga0on _Test 31 OAT O 2olp t
—public Water Supply (Community or Non-Communify/DEP)---CommordagIndusmal _Eanh-Codpled Geothermal 41 V
_•Golf course IMgation HVAC Su•.)y r
-_Class I Injection PP
Class V lnjec0on: _Recha a —HVAC ReNrth
r9__COmmercfeUlndusidelgapowi_AquifarStorageandRecovery�Dramage HinStLuciecou ty
Remediafion; _Recovery _AlrSparge _Otherlorvmel EN RONMENTALH TH _Other to.sassl OMcial Use only
I0,•Distanee from Septic ne Notretypeq�(wcan�erBe^aiedh'e?.ee rcnNn6g aemoriy) •..
p• System it s200 R 7 f it. FaGtity Desaipfion S fc
13'Esbmated Well Depth (� h, 'Estimated Casin9 D th i"a 12. Estimated Start Dale
ep h. 'Primary Casing Diameter Z la 14. Estimated Stirs Interval: Frort�To__R Open Here. From_Ta _fl.
iVisfinary Casing Material: Black Steel—Galmnbzed
__NOICased Outer: PVC-_SmInlws Steel
6. Secondary Casing: _Telescope Cedna __ Liner __ Surface Casing Diameter __ h
7. Secondary
of o s trru Mon. Re _Black Steel Galvanlzetl _PVC _ Stainless Steel _Other_�—
a.'Melhotl ofConsWdlon. Repair, orAbandonmrnh er
_Combination O'wo or More Methods) mug —Cable Tool __Jetted Rotary' _Sonlc
,Horl2Dnlallhaimg � Ruggedbyppimo Od —Hand (WrJl Point, Sand Point) Hydraulic Point (Direct Push)
_OMervotnmes)
3. Proposed Grouting interval for the Primary, Sawadary, and Additional Casina:
20.Indkatetatalnumberole)dslbrgwe0soneile - _-_- V�•c�— t
List number orefdsung unused mils an site
21.•Is this well or anyetus0ngvre1l orwatewilhdrawalon the owner., contiguous propody coveredundera ConsumpPermit (CUpfWUP)
tivaNVateftrse Or CUPNVUP Applirathm?_Yes "2No Ifyes, complete the following: CUP/WUP No.
22. Latitude�—_ Longitude Distdd Wall ID No.
23. Data Obtained From:_GPS _Map `Survey Darum:__NAD27
ub,ymhmaivo�:e ab4t er.,m.enw. Aeo:,ere..eae.me.,....e T_NADa3
w.+ra.va,.r.m�an...,......-.-_�-arm, ,_.............._.__. _ WO560
nype..•.a,mevo nY �
Issue Date Ip D Erpiraaon Date /
Fea Receked tI- � HydrokgktAppoval
R--eiF Na mtn
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BYAN AUTHORnc^ Cheri:
PERMIT SMALL HEAVAMBLEATTNSWELL SITE DURING ALL CONSTRUCnW(CREPNR MODIFICATION, ORABANDONM NTACTMSENTATIVE OF THE M4D OR TIE9.0 AUTHORDY, THE
DSP F.=a23a2.9a0(1) Inmryeretsd lnab532A600(Tl FA.C. Egeclive Date: October 7,2010 ... .._._ I
,,rram• •..... ...Page aol2
Rick Scott
Mission: Govemor
To prated, promote & impmve the health
Mall people In Florida through Integrated �,•=^g-}j-�; Celeste Philip, MD, MPH
state, county & community eBods. ; ;� ; ; `;
HULI I„I Slate 3urgeon General and5eaelary
Vision: To be the Healthiest State In Ile Nation
Florida Department of Health in St. Lucie County
Conditions for Issuance of Water Well Permits
SCANNED
Effective July 24, 2017 BY
St. Lucie Count,
• 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
S LC DO H-WELLS@ FLH EALTH. G OV
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 FLHEALTH.GOV
• Submit revisions to permit and/or site map and associated fee within 48 hours of well
construction or abandonment.
Florida Department of Health
SL Lucie County • Division of Disease Control and Health Pmleclion
Bureau of Environmental Health
5150 NW NLlner Drive
Pont SL Lucle, FL 34983
PHONE: 772/8734931 • FAX: 772/595-1308
FlorldaHealth.gov
Accredited Health Department
Public Health Accreditation Board