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Mate or Callfornle <br /> Department of Water Resources <br /> Central District <br /> 32515 street <br /> Sacrannonto,CA 93e1e 7017 <br /> OWNER'S REQUEST FOR WELL DRILLIER'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) C,o <br /> Street Address 2 ZoP S 6 <br /> Township_, s. RangeSection 1/2, 1/4 or 1/4 1/4 Section <br /> (City or County Planning Department may be■tile to furnish thls information) <br /> Assessors Parcel Number(on tax statement) '��7' d 54�> <br /> (If posslbla, please attach a copy of the Assessors Parcal Map.) <br /> Subdivision or Tract "' Lot No. Parcel <br /> Owner when well was drilled <br /> Other Previous Owners &, a2 <br /> Well Drilling Contractor or Company 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 pen�nit� 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 am the Owner of the well Please send a copy of the water <br /> descritw above. well drillers report to: <br /> Slflnature Name <br /> Name Company <br /> 3301 Ladd Rd. <br /> Modesto, CA 95359 <br /> Address Address <br /> City, State and 7-1p Code City, State and Zip Code <br /> Telephone Number Telephone Number <br /> Date '�� <br />