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02/06/2004 11:02 9168610410 SECOR PAGE 02/1 <br /> 'LLMMML 11151K11• ) 1�L( • IVVV �vn +�� �` �� � + •�f <br /> State of Cnllforr+la <br /> Department of WAW Rdsourc6s <br /> Oentral District <br /> 3261 a street <br /> Sacramento,CA*•66616-7017 <br /> WELL DRILLER'S REPORTS <br /> INSPECTION REQUEST AND AGREEMENT <br /> Location: ' l <br /> County: __ a A o o� ll t h� Contract Number: <br /> Request is made pursuant to Section 13751 of the California Water Code for permission to <br /> Inspect or copy Water Weft Driller's Reports which are on file 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 /> Inspection by the public but will be used solely by this governmental agency for making <br /> stt,des• If copies are made or taken, each copy wilt be stamped "CONFIDENTIAL' or "FOR <br /> OFFICIAL USE ONLY" and will be kept in a restricted file, access to which is limited to the staff <br /> of this goverrnental agency or to its contracted agents. Any copies fumished to contracted <br /> agents must be returned to the Department of Water Resources, Central District upon <br /> completion of work by the contracted agent. <br /> No information contained in these reports can be disseminated cr published without the written <br /> permission of the owner of the well. <br /> Ga-Q '� C - E F4 D G.I�-- �h��rh�-�lo� tet.• on oa ut,n ov <br /> Contracted Agent Goverhmental Agency <br /> �ac - e I a4 cr Avt <br /> dress <br /> Address re - <br /> GoC8,401ja-, C� �t s6'7 G car za 2 <br /> -City,Siete,8-Zip Code W.,CIty..State..b Zip.Code <br /> Ely ` +aCic 1 a&r- n By tt <br /> per J Officer <br /> C=61's+ - — 9-04E -Loi' llSr <br /> Title UTitle <br /> -61�- 0400 20S <br /> Tetephorin Telepnone <br /> VyDate Date <br /> (Fer o0WWoKft kMMMftL _oma W4. S <br />