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EA ENGINEERING, SCIENCE, AND TECHNOLOGY <br /> 41 LAFAYETTE CIRCLE <br /> :.AFAY£TTE, CA 94549 <br /> Q <br /> WELL INFORMATION <br /> XAME_..LudSuj0=X1LL_1.Y9r ........ DATE_____ <br /> _�� <br /> ADDRESS_, 3 _14 _ ally -_-_ HOME PHONE_________________ <br /> 6, ------------- WORK WORK PHONE------------___---_ <br /> HOUSE LOCATION (road junction, lot number, distances) <br /> -------------------------------------------------------------- <br /> Humber ofpeaple living in house/ ueiness <br /> Any babies lees than 1 yr, nld or expectant mothers? <br /> Do you own -- or rent,,,____ our mag <br /> _ Y i� <br /> Are you the original owner?__Nd _ <br /> If no, whet is the original owner's name? - -�-__ <br /> If you rent, what in the owner's name? <br /> 11#� <br /> -- --------------------- <br /> V <br /> Owner's address-- -------- <br /> _________ <br /> _______ ________--------------- -_____ <br /> Owner's }shone number----------.,-_------_ <br /> [ 40-1-931 Type of wells Bored_____ Drilled------ <br /> I � --- -------------,.__----_---- Dug------ Jetted <br /> Driller's name <br /> t Approximate installation date_ ^�' 1� -_- <br /> Well depth__________________ <br /> Well screen material: Steel_____ Plastic_____ Concrete--_-_ <br /> Wood_____ Brick Other <br /> House water pipes material: Lead_____ Plastic-__,__ Copper_____ <br /> Other-------------..�___ <br /> Outside spigot? Yee____ No____ <br /> Pump type: Oasa Electric - Hand <br /> Do you have a rater pressure tank? YesNo____ <br /> Do you have any kind of water treatment of softener? Yes____H�__r _ <br /> 1 <br />