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Person,Firm or Corporation <br /> 119 ALBERS ROAD MODESTO California 95357 <br /> Address City State Zip <br /> Signed: electronic signature received 12/01/2025 668622 <br /> C-57 Licensed Water Well Contractor Date Signed License Number <br /> DWR Use Only <br /> CSG# State Well Number Site Code Local Well Number <br /> ---- ---- ---- N ---- ---- ---- W <br /> Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br /> APN: -- <br /> Township: Range: _ <br /> Section: Tract: <br /> SEQ: BM: I <br /> No Attachments <br /> DWR Form 188 rev 10/09/2025 Page 3 of 3 <br />