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IY ll�ni.- ✓1.'JII�.LVI lU LGf - ( VVV ( JCr, 11 70 1G ;t>4 NU .UU� I .IJL <br /> Met,*of California �f�/i /Gay C vim' jf <br /> Department of Water Resaur as U <br /> trict <br /> 2a Central Str <br /> Sacramento.CA 95516-7017 <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 stro®ts, 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) C <br /> StreetAddress <br /> Township / 0. Range Section _ 1/2, 1/4 or 1/4 1/4 Section <br /> (City or County Planning Department may be able to furnish this Information) <br /> Assessor's Parcel Number(on tax statement) 1-7 Ja <br /> (if possible, please attach a copy of the Aesessor's Parcel Map.) <br /> Subdivision or Tract "' Lot No. Parcel <br /> Owner when well was drilled <br /> Other Previous Owners <br /> Well Drilling Contractor or Company 7 Year Drilled ? <br /> Depth of well (if known) _ Diameter& type of casing <br /> (This information is necessary If you have more than one well.) <br /> Section 13752 of-the California Water Code perfnits 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 /> I certify that I aim the Owner of the well Please send a copy of the water <br /> de d above, well drillers report to: <br /> Si ature Name <br /> Name George to Velde Jr. Company <br /> 3301 Ladd Rd. <br /> Address IV150010,CA 953515 Address <br /> City, Slate and Zip Code City, State and Zip Code <br /> Telephone Number Telephone Number <br /> ate <br />