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58 <br /> WORK ORDER DATE - Z':5__ <br /> WELL APPLICATION-WELL PERMIT / p PAID FEE <br /> Property Owner r.GGc.Li 6'?o Location/Direction: <br /> Person Requesting: , ,�y, � � Address d - Telephone No. - 7 <br /> (If different from owner - authorized by owner: YES NO <br /> TOWNSHIP TAX MAP NO. BLOCK: LOT: TYPE WELL: ��_L '� <br /> WELL CONTRACTOR G N)7U STATE REG. NO. ADDRESS <br /> OWNER OR AUTHORIZED AGENT: l~ r\ r\ <br /> (This signature indicates pernflssion ha een granted to enter p' e y fo ur s authorized by this work <br /> Nrd <br /> Signed: DATE: <br /> 11 S itarian <br /> WELL LOCATION, INSTALLATION, AND PROTECTION MUST MEET STATE AND LOCAL REGULATIONS A ST BE INSPECTED AND APPROVED BY <br /> A MEMBER OF THE ORANGE COUNTY HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE IST LATION IS PUT INTO USE. THIS <br /> 7,� <br /> PERMIT IS VALID FOR ONE (1) YEAR FOLLOWING DATE OF ISSUANCE. <br /> COMPLETION INFORMATION <br /> Well size: l(J�E) Well Depth: �5 Casing depth:, :5 Grou ing pth ?91—T.Vpe' Grouting: <br /> Well Yield: G.P.M. Static water level: CS Date Comp e e <br /> "Driller on site: Approved by: Date: <br /> S ari / <br /> GRID SPACE <br /> 136 12-9- D v � <br />