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. WELL SURVEY QUESTIONNAIRE <br /> Dear Occupant Date <br /> The following is an independent survey regarding the location and number of water supply wells in <br /> your neighborhood Please complete the following questionnaire Should you have any questions <br /> please contact ETIC Engineering, Project Manager,at <br /> 925-602-4710 Thank you for your cooperation <br /> 1) Owner name Phone# <br /> Address <br /> 2) Occupant name(if other than owner) Phone # <br /> Address <br /> 3) Is there a water supply well(s)on the property? (circle one) Yes No Unknown <br /> If so,how many? (number) <br /> 4) What is the current status of the well(s)? (circle one) In use Not in use <br /> 5) What is the water currently used fort (circle as many as apply) <br /> Drinking water Other household use Landscapelrrrgation Monitoring <br /> 6) Is there a basement on the property? (circle one) Yes Na <br /> 7) Is there a sump in the basement? (circle one) Yes No <br /> Please remit to ETIC Engineering within 3 working days of receipt of the questionnaire Thank you <br /> • <br /> • <br />