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EA ENGINEERING, SCIENCE, AND TECHNOLOGY <br /> 41 LAFAYETTE CIRCLE <br /> LAF'AYETTE, CA 94545 <br /> s <br /> WELL INFORMATION <br /> 02 j <br /> MA -------- DATE_6 _j-'7 _______ <br /> ADDRESS j/AL0A HOME PHONE----------------- <br /> WORK <br /> _-..--__w____----WORK PHONE <br /> HOUSE LOCATION (road junction, lot number, distances) ________ <br /> ---1 °` -------------------------------,--------- <br /> Number ofpeople living in house/buaineas__�___ <br /> Any babies lase than 1 yr. old or expectant mothers? <br /> Do you own_____ or rent" 2_ your house? <br /> Are you the original owner?_[h4 <br /> If no, what is the original owner's name? <br /> ... <br /> If you rent, what is the owner's name?_________________,_____-_ <br /> Owner's address <br /> ------------------------------------------------ <br /> Owner's phone number.................... <br /> Type of well: Bored_____ Drtlled_y_ Dug______ Jetted__-__,., <br /> Drillers name—&-t1-6-44til <br /> Approximate installation date_-.,-"—w-COL <br /> Well depth__I7 -------------- <br /> Well <br /> _` ------Well screen material: Steel_ Plastic_____ Concrete_____ <br /> BrickOther-_....-- -------_ . <br /> House water pipes material: Lead----- <br /> I -`Plastic____- Copper_____ <br /> . Other_ <br /> Outside. spigot? Yea-/ <br /> _ . fio---- V <br /> Pump type: GeeElectric_ Hand-__-__ <br /> Do you have a water pressure tank? Yes_ No---- <br /> Do you have any kind of water treatment of softener? Ye ---- ---- <br /> I <br />