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i o <br /> WELL SURVEY QUESTIONNAIRE <br /> IDate Cn v" CAC6 <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 /> IThank you for your cooperation <br /> 1) Name of Property OwnerPhone No1 <br /> Address <br /> 2) Name of Tenant Phone No ��a �2� -'�'• <br /> Address _. ( moo Sc r>•1� +v��.a E1�A ----- <br /> 3) Are there wells on the property) (circle one) yes no I don't know <br /> 4) Number of wells C 5) WeII diameter LA <br /> 6) Well Depth L1( - _ <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other LA <br /> 8) Date of Installation Ll <br /> 9) Frequency of use -LL c_� <br /> 10) What is the well used for? 'T c: 5 'S L LA5 C (,-)o <br /> (circle one) Drinking water Agriculture Monitor groundwatert�describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES -O- <br /> Additional Information and/or Comments `T��-'� c) MS <br />