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EA ENGINEERING, SCIENCE, AND TECHNOLOGY <br /> 41 LAFAYETTE CIRCLE <br /> LAFAYETTE, CA 94549 <br /> WELL INFORMATION <br /> It <br /> NAME---------------------------- DATE____"�!0f ------ <br /> ADTiRI:SS_Dt� <br /> 116�! �I�} N!�� �'! L� HOME PHONE----------------- <br /> WORK PHONS--„,,___._---------- <br /> HOUSE LOCATION (road junction, lot number, distances) __...._,,. <br /> SAAK 1J1 _--� D_{kT_Z-..wIt� _—_------ <br /> Number ofpeople living in house/business,„,______ <br /> Any babies less then 1 yr. old or expectant mothers?_1 17” bOk <br /> Do you own_��or rents_____ your house? <br /> Are you the original owner?________ <br /> It no, wheat to the original owner's none?�Y�_---�----_--._..._____ <br /> If you rent, what is the owner's name? <br /> Owner's address------------------------------------------------ <br /> Owner's phone number-------------------- <br /> Type of wellt Bored_____ Drilled___ Dug------ Jetted__„__-- <br /> Driller'a name___----------------------- <br /> Approximate installation date___________________ <br /> Edell depth___-,______________ <br /> Well screen material: Steel----- Plastic_____ Concrete_-___ <br /> Hood__--- Brick...... Other-------------- <br /> House water pipes material- Lead----- Plastic_____ Copper____- <br /> Other----- ------------ <br /> Outside spigot? Yes_J_A�No—w` <br /> Pump typei Gas Electric Hand <br /> Do you have a water pressure tank? Yea-__- No____ a}gpf, <br /> Do you have any kind of voter treatment of softener? Yea----No <br /> 1 <br />