Permit Well 319 12th St 2011 A \
` 4 f CITY OF ATLANTIC BEACH
4.....r.0 sa 800 SEMINOLE ROAD
" = ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
Application Number 11- 00002194 Date 6/17/11
Property Address 319 12TH ST
Application type description WELL PERMIT
Property Zoning TO BE UPDATED
Application valuation . . . 0
Application desc
new well
Owner Contractor
HUDSON WILLIAMS WELL DRILLING INC
319 12TH STREET P. O. BOX 330567
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241 -8489
Permit WELL PERMIT
Additional desc .
Permit Fee . . . 75.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 12/14/11
Special Notes and Comments
Seperate permit required for electrical
connection /wiring to new pumps
Other Fees STATE DCA SURCHARGE 2.00
STATE DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 75.00 75.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 79.00 79.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
S y:Vi:,..,. City of Atlantic Beach APPLICATION NUMBER
, Building Department 4/4/ V (To be assigned by the Building Department.)
r :� 800 Seminole Road , /
L.' � '4.1.°" �� Atlantic Beach, Florida 32233 -5445 �Y' Z of/ // r 9 y
Phone (904) 247 -5826 - Fax (904) 247 -58' I
`';%�`0 % E -mail: building- dept @coab.us Date routed: W /7/ //
City web -site: http: / /www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 2/ / /(? ' " 4 Department review required Yes No
P A Y p q
//) Building
Applicant: kl/// A UV t LC Planning & Zoning
Tree Administrator
Project: iO 1 E /� Public Works
. blic Utilitie
Public Safety
Fire Services
ReVievir feEr $ :! - 4 } , t , : „ 0.01T ept Signature 4 Ag , ?.:F t
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS ii
Reviewing Department First Review: 'Approved. ❑Denied. n �
(Circle one.) Comments:
BUILDING
4
PLANNING & ZONING Reviewed by(
Date: (p// // �?
TREE ADMIN. Second Review: A ~j
❑ pp roved as revised. ❑Denied.
PUBLIC WORKS Comments:
P 4 : LIC UTI
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. (Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
(---''
CITY OF ATLANTIC BEACH
WELL PERMIT APPLICATION
Date '" //
Owner' s Name: /4/01?> Address: 3 / !7'7'4 S7
Well Address (if different than above):
Well Location on Property (i.e. northeast corner, etc.) ,/ZS I4 t� FQ4 e r ovde�
Well Installation Contractor: (r2 /4 42e7 /"/ / e_ic._
Contractor License No.: /4 7 Phone: ,37 1.32? FAX:
Contractor Address: /, D ✓�" 3 y ✓ ' / f/ /c____
�✓��
Check Use of Well: Domestic Irrigation Other
Estimated- Well Depth: /6 ?) Casing Depth 3 v Screen Interval from /0
Well Diameter: , j Casing Material! a
Is address currently connected to the City water system? G0',4
Is address currently connected to the City sewer system? ill
Has a Well Permit been obtained from the City of Jacksonviille ?V 0 Permit #
Does the well require a permit from the St. Johns River Water Management District?
(Not required for wells under 2- inches diameter installed by resident or wells under 6-
inches diameter if installed by licensed well contractor). ,/ O
If permit is required, note Permit Number'► ' 2 t I lnd attach a copy.
NOTE: WHENA WELL IS INSTALLED ON YOUR PROPERTY, YOU MUST
INSTALL A REDUCED PRESSURE ZONE TYPE BACKFLOW PREVENTER ON
THE CITY WATER SERVICE, ON THE CUSTOMER'S SIDE OF THE METER.
THE BACKFLOW PREVENTER MUST BE TESTED BYA CERTIFIED TESTER
AND A COPY OF THE RESULTS SENT TO THE PUBLIC UTILITIES
DEPARTMENT.