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i <br /> r <br /> JOIN 7AA - <br /> { EA ENGINEERING, SCIENCE, AND TECHNOLOGY <br /> 41 LAFAYETTE CIRCLE <br /> LAFAYETTE, CA 94549 <br /> ' WELL INFORMATION <br /> ' NAME A ....» q ,J --- <br /> ADDRESS_ 2-�?Z-k"�-Y�C- _ri,- HOME PHARE , (�=L ✓ ter <br /> ------------------------- WORK PHONE.... <br /> HOUSE LOCA'T'ION (road junction, lot number, distances) ________ <br /> -_------ -----------------------_----------------•-••--•-__...___-- <br /> Number ofpeople living to houeuaineOs <br /> Any babies less than 1 yr. old or expectant mothers?____ <br /> Do you ownor rank__..__ your house? <br /> Are you the original owner?_ <br /> lei <br /> If no, what is the original owner's name?_ _____ � _� <br /> If you rent, whet is the owner's name? ____________ <br /> Owner's address---------�Lcr=_�---------------------------------- <br /> Owner's phone number__ __�_+_-" ------ <br /> Type <br /> _ __Typic of well: Bored_____ Drilled__ _ Dug_--_ - Jetted____•__ <br /> Driller's name-------------------------- <br /> Approximate installation date__1 <br /> Well depth__ [S'e 1 O 0_-- <br /> Well screen material: Steel_L_ Ploattc_GL_ Concrete_-___ <br /> Wood__--- Brick______ Other <br /> House water pipes material: Lead_____ Plastic__,___ Copper_____ <br /> Other <br /> - —x— <br /> Outside spigot? Yps No- <br /> Pump type: Goa----- Electric Hand /� <br /> Do you have a voter pressure tank? Yen- k! No____ <br /> Do you have any kind of water treatment of softener? Yes....No-�� <br />