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<br />
<br />I'S
<br />,_~ ' APPLICATION TO CONSTRUCT, REPAIR, MODIFY OR ABANDON WELL
<br />j',,", '~'~
<br />; r ", ;, ~ SOUTHWEST FLORIDA
<br />.,' / WATER MANAGEMENT DISTRICT
<br />,\"",,-,' 2379 Broad St., Brooksville, Florida 34609-6899, (904) 796-7211
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<br />Permit No, 'd
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<br />WUP Application No,
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<br />17 -524 Well
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<br />Owner Number
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<br />Stipulations Required
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<br />1.
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<br />Telephone Number
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<br />2. L) rtl n1 }:f i<T ..., ,/7- S-
<br />Well Location: Address, Road Name or Nurrt6er
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<br />3. L08,.Js* e.,- L....JP II O,..-II,'V1 q
<br />Drilling Contractor' .....)
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<br />7. zil- ?z-
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<br />Date
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<br />210 '3
<br />License No,
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<br />Address
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<br />OT'5 fJlI,o.-, {)~,.o &~Jrh: 1J 5.
<br />City I r State I
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<br />rl. 3 5 _5"'-1 ()
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<br />Zip Code
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<br />l,tcoso
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<br />4. Number of Wells:-1- . Check the Use of the Well:
<br />_ Domestic v1rrigation
<br />_ Public Water Supply _ Heat Pump! AC Supply
<br />_ Recovery _ Class V, Heat Pump! AC Return
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<br />_ Livestock
<br />_ Industrial
<br />_ Class I Injection Well
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<br />_ Test (WUP)
<br />_ Monitor (Type)
<br />_ Other
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<br />5, Application for: 6. Casing _ or Liner _ (Check One)
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<br />v--- New Construction _ Black Steel - PVC
<br />_ Repair/Modify vGalvanized Other (Specify)
<br />_ Abandonment
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<br />7. Method of Construction: _ Rotary t/""Cable Tool _ Combination _ Auger
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<br />8, P8S0('")
<br />County Subdivision Name Lot Block
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<br />1/
<br />~L- Diameter
<br />Seal Material (Specify)
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<br />Other
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<br />9, Quarter Quarter Section
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<br />Unit
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<br />~ (Indicate Well in Chart)
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<br />10.section~ Township ;2.5'"" Range 2./
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<br />Dra~ map of well location and indicate well site
<br />with an ,"X", Identify known roads and landmarks;
<br />provide distances between well and landmarks.
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<br />North
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<br />11, On 6-inch wells & larger:
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<br />Latitude
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<br />Longitude
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<br />, t,\,.
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<br />E
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<br />License No,
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<br />....
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<br />13,/5 this well or any other well or water withdrawal on the owner's contig
<br />a Water Use Permit (WUP) or WUP application?
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<br />Yes _ NU- If yes, provide WUP No.
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<br />the owner of the property. that the informa on well location is accurate, and that I 8m aware of my
<br />nder Chapter 3 Florida Statutes, to maintain or properly abandon this well; or, I certify that I am the agent for the
<br />ed s ae te, d that I have informed the owner of his responsibilities as stated above.
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<br />South
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<br />Owner Number:
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<br />Fee Received $:
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<br />,_,.,--...... _ Date:
<br />Check No,:
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<br />Title:
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<br />.~ THIS PERMIT NOTVALlD UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OF SWFWMD(R), IT SHALL BE AVAILABLE AT THE WELL SITE
<br />~, DURING ALL DRILLING OPERATIONS,
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<br />SF 30613) REV 4/90
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<br />DRILLING CONTRACTOR COpy - 1
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