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Vv1 �J� <br /> WELL SURVEY QUESTIONNAIRE <br />' Date v err G <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 /> 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 / Phone No <br /> Address <br /> 2) Name of Tenant M� Sp.,�„c - � , y_ Phone No <br /> Address 2i <br /> 3) Are there wells on the property'? (circle ane) Qes no I don't know <br /> 4) Number of wells Oil C 5) Well diameter <br /> 6) Well Depth U <br /> 7) Well materialcircle one)) PVC Plastic t c Steel Brick/clay Other <br /> 8) Date of Installation u <br /> 9) Frequency of use <br /> 10) What is the well used for9 <br /> (circle one) ri�waterAgriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES NO <br /> Additional Information and/or Comments =-L <br />