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WORK ORDER DATE �_ �(o ?7 <br /> a�.G <br /> y��ds ��]7 WELL APPLICATION-WELL PERMIT PAID FEE SG.Oo <br /> Property Owner �� //iLti(--' Location/Direction: <br /> Person Requesting: m mG �iGGc� Address , _ 7, Telephone No. 6 <br /> (If different from ouqner - authorized by owner: YES NO <br /> TOWNSHIP ,lip TAX MAP NO. BLOCK: LOT: TYPE WELL: <br /> WELL CONTRACTOR � T STATE REG. NO. ADDRESS <br /> OWNER OR AUTHORIZED AGENT: <br /> (This signature indicates permiss n has been granted to enter proper y for purposes authorized by this work order. <br /> Signed: DATE: le AA4 <br /> Sanita ian <br /> WELL LOCATION, INSTALLATION, AND PROTECTION MUST MEET STATE AND LOCAL REGULATIONS AND MUST BE INSPECTED AND APPROVED BY <br /> A MEMBER OF THE ORANGE COUNTY HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS PUT INTO USE. THIS <br /> PERMIT IS VALID FOR ONE (1) YEAR FOLLOWING DATE OF ISSUANCE. <br /> COMPLETION INFORMATION <br /> Well size: Well Depth: Casing depth: �z- Grouting depth: �� T pe Grouting: lVI1J 1 '� L� <br /> Well Yield: ^ G.P.M. Static water level: �_ Date Comp la <br /> Driller on site: Approved by: Date: - <br /> S itaria <br /> Jff <br /> GRID SPACE <br /> 1/�e�� 5 5'gJ C��� <br /> 64 A_44 <br /> s� _ g_zc,•sg C�,,,Q,b I <br /> (A Oki <br /> d S <br /> s K AX// �,� �, r �o P wa,,.�� �°�"� yz 4� <br /> dam'" ,sue <br />