1632 W park Ter 2012 well CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
Application Number . . . . . 12-CO000946 Date 8/23/12
Property Address . . . . . . 163 : W PARK TER
Application type description WELL: PERMIT
Property Zoning . . . . . . . TO EE UPDATED
Application valuation . . . . 0
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Application desc
WELL
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Owner Contractor
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AYCOCK THOMAS J III & MARY ANN WILLIAMS WELL DRILLING INC
491 SATURIBA DR P. 0. BOX 330567
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241-8489
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Permit . . . . . . WELL PERMIT
Additional desc . .
Permit Fee . . . . 75 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/19/13
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Special Notes and Comments
Seperate permit required for electrical
connection/wiring to new pumps
A reduced pressure zone backflow preventer must be
installed if irrigation will be provided or if there is a
private well on the property. Backflow preventer must be
tested by a certified tester and a copy of the results sent
to Public Utilities .
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Other Fees . . . . . . . . . STAT!E DCA SURCHARGE 2 . 00
STATE DBPR SURCHARGE 2 . 00
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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 A rLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
City of Atlantic Beach APPLICATION NUMBER
Building Department (TO be assoied by the Building Deparknent.)
800 Seminole Road
Atlantic Beach,Florida 32233-5445
Phone(904)247-5826 - Fax(904)247-5845
E-mail: building-dept@wab.us Date routed:
City web-site! http,/Aww.cosb.us I -
APPLICATION REVIEW ANP TRACKING FORM
Property Address: Department review required Yes No
Building
Applicant: Planning&Zoning
Tree Administrator
Project: Public Works
Public Safety
e Services
7RO low or Receipt
Other Agency Review or Permit Required Of P wmit Vedfied By Date
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Affny Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other
APPLICATION S TUS
Reviewing Department First Revilew: V%proved. FIDenied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed bl,:
TREE ADMIN. Second Review: ElApproved as revise:1. F]Denied.
ORKS Comments:
LI TILITIE
7
PUBLIC SAFETY Reviewed 6: Date:
FIRE SERVICES Third Review: []Approved as revisei I. ODenied.
Comments:
Reviewed by Date:
Revised 07127110
CITY OF ATLANTIC BEACH
WELL PERMIT APPLI[CATION
Date
Owner's Name:/_D /0 1&e—'6�Addrest
Well Address (if different than above): z—
Well Location on Property (i.e. northeast corner, etc:�
Well Installation Contractor:
Contractor License No.: zql 7, Phone;.Z:�.7-07ej� Fax:
Contractor Address: ",/ —5��e:5>
.1 1 Z?�4 - � /I
Check Use of Well: Domestic Irrigation 1�0/'�'Other
# of Wells to be installed: # of P imps to be installed:
Estimated- Well Depth:1'1'6 Casing Depth: Screen Interval fron3aftoA0
Well Diameter: Casing Material
Is address currently connected to the City water syst,,m? P
Is address currently connected to the City sewer sysi em?_
Has a Well Permit been obtained from the City of J ksonville? Permit#
Does the well require a permit from the St. Johns River Water Management District?
(Not required for wells under 2-inches diameter inst,illed by resident or wells under 6-
inches diameter if installed by licensed well contrac,or). '90
If permit is required, note Permit Number at d attach a copy.
I
NOTE.- WHENA WELL IS INSTALLED ON YO:11R PROPERTY, YOUMUST
INSTALL A REDUCED PRESSURE ZONE TYPAI BA CKFLO W PRE VENTER ON
THE CITY WA TER SER VICE, ON THE CUSTO)4ER'S SIDE OF THE METER
THE BA CKFL 0 W PRE VENTER MUST BE TES 1 rED B YA CER TIFIED TESTER
AND A COPY OF THE RESUL IS SENT To ij;�'PUBLJC UTILITIES
DEPARTMENT.