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03/17198 11:42 U510 895 8205 CHH HILL LNUU410"4 <br /> „CICNTRRL DISTRICT t227-7600 MRR 02 "S 15 :56 No .015 P.02 <br /> Stets Or C211famia <br /> Department of Water Restvn= �t <br /> Central DWd <br /> 8251 S street <br /> Sacmmeslt0,CA 95616.7017 <br /> WELL DRILLERS REPORTS <br /> INSPECTim REQUEST AND AGREEMENT <br /> project: <br /> Location: <br /> County: Contact Number: <br /> Request is mode pursuant to Section 13751 of tha Callibmia Water Coft for permission to <br /> Inspect or copy Water Well Driller's Reports which are on Me in your office. <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 /> inspet lon by the public but will be used soieiy by this governmenrat agency for rnaking <br /> studies. If copies are made or taken, each copy will be stamped 'CONFIDENTIAL" or"FOR <br /> OFFICIAL USE ONLY"and was be kept in a restricted file,access to which Is limited to the staff <br /> of this govetrnental agency or to Its contracted agents. Any copies turniahed to contracted <br /> agents roust be returned to the Department of Water Resources, Centra! District upon <br /> completion of work by the contracted agent. <br /> No information contained in time reports Can be disseminated or publishsd without lite written <br /> permission of the owner of the well. <br /> Centraoted Agent Govemineltrl Agency <br /> Address Ad4r@6s <br /> City,stere.&Zip Code City,sate.&Zip code <br /> Sy <br /> BY <br /> OfRster out" <br /> Tdle Title <br /> Teiepnane Telephone <br /> Date Date <br />\ (For o*P=e>m M 1nfixm25mn <br /> i <br /> 1 <br /> i <br />