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12 <br />4. Year Drilled: 5. Driller: <br />I authorize the Orange County Health Department staff or other <br />consultants/contractors designated by Orange County to enter my property to <br />determine if a .well failure exists. I understand the determination can involve <br />water samples, pump tests or other procedures necessary to fully evaluate the <br />well and water supply system. <br />OWNER: DATE: <br />