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WELL SURVEY QUESTIONNAIRE <br /> Date 5-g2> <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 !1 -'r-- ,�— �,� �� 'AA A ; r <br /> 2) Name of Tenant / Phone No <br /> Address <br /> 3) Are there wells on the property9 (circle one) es no I don't know <br /> 4) Number of wells A-7- -- 5) Well diameter LA <br /> 6) Well Depth <br /> 7) Well material (circle one) PVC Plastic <br /> Steel Brick/clay Other L1 <br /> $) Date of Installation <br /> I9) Frequency of use LAA <br /> 10) What is the well used for9 T <br /> (circle one) Drinking water Agriculture Monitor groundwater Ala=— (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES N) <br /> Additional Information and/or Comments ,AAL-_ <br />