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f <br /> staffs or California «�, � �� �_ <br /> Deputment of Water Resources <br /> Grttral Dl�trtct <br /> 32515 Ctrest <br /> Sscmrnonto,CA 95atsaal7 <br /> OWNER'S REQUEST FOR WELL DRILLER'S REPORT(WELL-LOG) ' <br /> Please use the back of this page to sketch the location of your well. Adequate Information <br /> must be provided before a search for the well log can begin. Give distances and directions <br /> from cross streets, Show landmarks such as schools, post offices, historic sites, highways, <br /> county roads, main streets, etc. (Indicate North on the sketch). <br /> Location of well (City and County) ,o oA 4,i/U cd <br /> Street Address a S<5 <br /> Township / S, Range�_ Section _ U2, 114 or 1/4 1/4 Section <br /> (City or County Planning Department may be sbls to tumish this Information) <br /> Assessoes Parcel Number(on tax statement) ZO 7— 0542 42 2- —2- <br /> (if <br /> 2- <br /> (lf possible, please attach a copy of the AsaeasoYs Parcel Map.) <br /> Subdivision or Tract "' Lot No. — Parcel <br /> Owner when well was drilled <br /> Other Previous Owners �e- <br /> Well Wiling Contractor or Company' 7�--h /✓�/��%✓�1'aar Drilled <br /> Depth of well (if known)3<: ,Y Diameter&type of casing <br /> (This information Is necessary if you haus more than ons well.) <br /> Section 13752 of the California Water Code perrinit�release of water well drillers reports only <br /> upon the written request of the owner of the well. The owner's certification must be completed. <br /> 1 certify that I am the Owner of the well Please send a copy of the water <br /> descri above. well drillers report to: <br /> Signa re Name <br /> Name Company <br /> Address Address <br /> City, State and Zlp Code City, State and Zip Code <br /> Telephone Number Telephone Number <br /> Oates <br />