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r <br /> r <br /> rWATER SUPPLY WELL LOCATION SURVEY FORM <br /> POZO DE AGUA POSICION/ FORMA DE ENTREVISTA <br /> rSECOR International <br /> 3475 West Shaw Ave, Suite 104 <br /> r Fresno, California <br /> (559)271-2650 <br /> F' October/Octubre 2004 <br />' Well Survey Site Address/Pozo de Sitio de Entrevista f <br /> Street/Calle , 5� t k w <br />' Crty/Cuidad <br /> State/Estado, Zip Code/C6digo Postal221� <br /> e i No <br /> A water well is present on the property?/Un pozo de agua esti presente sobre la <br />' caracteristtca(proptedad)? <br /> Domestic/Drinking water well/Pozo de agua Dom6stico/potable <br />' AgnculturaVLandscape water well/Pozo de Agua agricola/paisale <br /> Unknown/Desconocido <br />' ) e Si No <br /> Is the well being used?/LPozo el es usado? <br />' known,please provide well construction details/Si conocxdo,por favor summistre pozo detalles de <br /> construcci6n <br />' Date installed/Fecha mstalada- <br /> Depth of well/Profundidad de Pozo <br /> Casing T ype/Tipo de Cubterta, <br /> r Casing dlameter/Dllimetro de cubierta <br /> Screen mtervaMtervalo de pantalla <br /> rSurvey completed by/R.evxsi6n completada por <br /> Name/Nombre. S hanie Furgal of SECOR for homeowner/busmess owner <br /> r <br /> Signature/Firma. 4�-X-L 24A C"-) <br /> rDate/Fecha �b <br /> r <br />