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i <br /> w <br /> WELL SURVEY QUESTIONNAIRE <br /> Date <br /> To whom it m n <br /> may concern <br /> We would appreciate your help by completing the following questionnaire regarding the existence <br /> of wells on your property This information will be provided to Public Health Services of San <br /> Joaquin County Please fill out the survey to the best of your knowledge, even if you don't have <br /> a well Should you have any questions, contact Gary Rogers (Remedy, Inc ) at (510) 791-7157 <br /> Thank you for your cooperation <br /> I1) Name of Property Owner N 14 i 2O ZG) Phone No / <br /> Address Zs-, :�7 ys� ��__ ►� __��n ,�} <br /> 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property (circle one) Qes no I don't know <br /> 4) Number of wells o E 5) Well diameter l.A <br /> 6) Well Depth 0 <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> LA- <br /> 8) Date of Installation LA <br /> 9) Frequency of use <br /> 10) What is the well used for'? ti T.�� s r S <br /> (circle one) Drinking water Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments <br />