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t - -- . _ _� � •�� i�u .uur r .u2- <br /> 1 <br /> �itete of Oalltornte `7/c C.-c. —// <br /> DePattment of Water Resources <br /> Central District <br /> 32515 West /✓�%r�`� �///'7 <br /> Sacramento,CA ssele 7017 <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 sA '55"6 Co <br /> Street Address <br /> Township _. Range Section _ 1/2, 1/4 or 1/4 1/4 Section <br /> (City or County Planning Department may be able to tumish this Information) <br /> Assessor's Parcel Number(on tax statement) ��7' a Jrd - O <br /> (if possible, please attach a copy of the Attestors Parcel Map.) <br /> Subdivision or Tract "" Lot No. Parcel <br /> Owner when well was drilled ��<' � 3'`� � �� ✓ <br /> Other Previous Owners <br /> Well Drilling Contractor or C_ompaYear Drilled <br /> Depth of well (if known)_w // Diameter& typo of casing <br /> (This information Is necessary If you have more than one well.) <br /> Section 13752 of-the California Water Code perrhit�_release of water well drillers reports only <br /> upon the written request of the owner of the well. The owners certification must be completed. <br /> I certify that I am the Owner of the well Please send a copy of the water <br /> descri d abovewell drillers report to: <br /> Sbn re Name <br /> Name Company <br /> Address Address <br /> City, State and Zip Code City, State and Zip Code <br /> Telephone Number Telephone Number <br /> ate <br />