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4 K <br /> WELL SURVEY QUESTIONNAIRE <br /> Date <br /> To whom it 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 /> I 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 /> 1) Name of Property Owner MQ- =" iuus<rq Phone No 231 - tbA6_ <br /> Address - A AZV�—1 -c <br /> f2) Name of Tenant A Phone No --14=1 � <br /> Address vk <br />' 3) Are there wells on the property9 (circle one) es � no I don't know <br /> 4) Number of wells cel C 5) Well diameter �-A <br /> 6) Well Depth ul <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other LA <br /> 8) Date of Installation LA <br /> I9) Frequency of use <br /> 10) What is the well used for? <br /> (circle one) rinks ater� Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YESNO <br /> Additional Information and/or Comments <br />