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Fd� 20 03 12: 30p Hr on Env. Inc 816 9 2172 p. 2 <br /> State of Callfbmla <br /> Department of Water Resources <br /> Central District <br /> 3251 $Street <br /> Sacramento, CA-95810-7017 <br /> WELL DIRKLER'S REPORTS <br /> INSPECTION REQUEST AND AGREEMENT <br /> Project r <br /> Location.- Z 5 �r G� <br /> Gdurrty: g-,Xu Jms,µ <br /> Contract Number - - r <br /> Request is made pursuant to Section 13759 of the California Water Code for permission to <br /> inspect or copy Water Well Driller's Reports which are on file in your of ice. <br /> In accordance with the requirements of Section 13752 of the Water Code, it is stipulated and <br /> agreed that such reports, or any copy or copies made thereof, will not be made available for <br /> inspection by the public but will be used solely by this governmental agency for making <br /> studies, if copies are made or taken, each copy will be stamped "CONFIDENTIAL" or "POR <br /> OFFICIAL., USE ONLY"and will be kept in a restriCed file, access to which is limited to the staff <br /> of this govErmental agency or to its contracted agents. Any copies furnished to contracted <br /> agents must be returned to the Department of Water Resources, Central District upon <br /> completion of work by the contracted agent. <br /> No information contained in these reports can be disseminated Or putlished without the written <br /> permission of the owner of the well. <br /> Contracted A�eni: rR� <br /> Co��vefm��nEntal Agency <br /> �Icdress <br /> �lf"_Lt� Ot{ gPilrlT>�� Mt1rARC <br /> Add:ess <br /> �--- ci s ,— <br /> City, Sta"e, B.Z-p r'^�'e <br /> 7 <br /> By � t <br /> By <br /> C] icer Officer <br /> UQ <br /> TMe els <br /> Title <br /> Tel Telephone <br /> ate <br /> Bate <br /> (For Deparin ental rnftmagan_ <br />