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1 , 4 <br /> { <br /> WELL SURVEY QUEST10NNAIRE <br /> Date <br /> To whom <br /> 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 �i (s-� oEp,) <br /> Address <br />' 2) Name of Tenant t-ns 4- axN3c Phone No to rQ <br /> Address -1 lb2-r <br />' 3) Are there wells on the property9 (circle one) yes I don't know <br /> 4) Number of wells / 5) Well diameter <br /> b) Well Depth / <br />' 7) Well material (circle one) PVC Plastic Steel Brick/clay Other / <br />' 8) Date of Installation <br />' 9) Frequency of use / <br /> 10) What is the well used fors <br />' (circle one) Drinking water Agriculture Monitor groundwater Other describe above <br /> g ( ) <br /> 11) Do you have a basement with sump pump (circle one) YES NO <br /> Additional Information and/or Comments <br /> way <br />