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Dear Resident <br /> November 5,2001 <br /> The following is an independent public health questionnaire to determine if any basements or municipal, domestic, <br /> or irrigation wells exist in the vicinity of Waterloo Road and Highway 99 in Stockton, California The San Joaquin <br /> County Public Health Services is requesting that we identify these features in the area as part of an ongoing <br /> environmental investigation <br /> Please fill out the following information to the best of your knowledge If you do not know, please answer <br /> "UNKNOWN" Even if there is no well or basement at the address listed, please complete items 1 through 5 and <br /> return the survey in the postage-paid envelope provided at your earliest convenience Should you have any <br /> questions, please contact the Cambria Environmental Technology, Inc protect manager listed below This <br /> information may be submitted via mail,facsimile,or verbally by telephone Thank you for your cooperation <br /> CAMBRIA ENVIRONMENTAL TECHNOLOGY,INC <br /> Aubrey Cool <br /> Project Geologist <br /> Phone (707)933-2368 Fax (707)935-6649 <br /> P O Box 259 <br /> Sonoma,California 95476 _ �` <br /> (1) PROPERTYADDRESS � tkO <br /> OWNER NAME DAYTIME PHONE <br /> TENANT NAME (if not owner) ri 2S 4 r P- ck-S DAYTIME PHONE C7'dt q3(—ZA!S <br /> d <br /> (2)Are there any wells at the address listed in item I (circle one) <br /> YES UNKNOWN <br /> (3)Are there any wells in the vicinity of the address listed in item 1 (circle one) <br /> aUNKNOWN NO <br /> (4)Are there any abandoned wells at the address listed in item 1 (circle one) YES UNKNOWN (.>D <br /> Comments <br /> (S)Are there any basements at the address listed in item I (circle one) YES UNKNOWN <br /> (6)If you answered"YES"to 2 or 3 above,please provide the following details,if possible If there is more than one well,please <br /> indicate which well you are describing <br /> WELL ADDRESS 1-l3`i`l G�hV er 1013 G�--c�rO i 1 WELL OWNER <br /> WELL WATER USE FREQUENCY OF USE <br /> WELL DIAMETER WELL DEPTH <br /> WELL MATERIAL (circle one) PVC plastic steel bnc /clay other <br /> SCREENED INTERVALS)OR PUMP DEPTH <br /> DATE OF INSTALLATION <br /> OTHER INFORMATION 6z�-5 �Cori 1 S,-�� Sammi�t-rq f So, .rlo r-�np5 <br /> 1359 <br />