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Contracted Agent <br />653 7 erha,,) eet <br />Address <br />City, State, & Zip Code <br />Ev 101 <br />Governmental Agency <br />Of <br />Addrcs5 <br />51-1<i/ ' CA <br />City, State, Zip Code <br />1€'4A-b-q <br />Officer Officer <br />(a?) 467 /O030 <br />Telephone <br />Date <br />Telephone <br />-42-7.1t) <br />cks' <br />Date <br />State of California <br />Department of Water Resources <br />Central District <br />3251 S Street <br />Sacramento, CA 95316-7017 <br />WELL DRILLER'S REPORTS <br />INSPECTION REQUEST AND AGREEMENT <br />f2a.a. - ( Projectl <br />Location:, !_,13 e)f)--- 5/0 0 t.) hi* *-47-430ApeCQ 11-1- <br />County: Skr-vi Contract Number: 141 414 e-3 V41.q <br />Request is made pursuant to Section 13731 of the California Water Code for permission to inspect or copy <br />Water Well 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 agreed that such <br />reports, or any copy or copies made thereof, will not be made available for inspection by the public but will <br />be used solely by this governmental agency for making studies. If copies are made or taken, each copy will <br />be stamped "CONFIDENTIAL" or "FOR OFFICE USE ONLY" and will be kept in a restricted file, access <br />to which is limited to the staff of this governmental agency or to its contracted agents. Any copies furnished <br />to contacted agents must be returned to the Department of Water Resources, Central District upon completion <br />of work by the contracted agent, <br />No information contained in these reports can be disseminated or published without the Nvritten permission of <br />the owner of the well, <br />Adoakc.,2_,9 G EE <br />Title Title <br />(Foy Departmental Information: Copieo sent <br />ZO/ZO 39Vd NaLADOIS 39V <br />8ETTL91760Z 017:TT NOVZVE0