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OW, <br /> CA ENGINEERING, SCIENCE, AND TECHNOLOGY <br /> 41 LAPAYETTE CIRCLE <br /> LAF'AYETTE, CA 94549 <br /> D ,,/ WELL INFORMATION <br /> NAHE_�I�� /y 1L �� ------ DATE_-¢����r----------- <br /> ADDRESS_. /KgL-I Ck r- --_-__ HONE PHONE--Y46- <br /> WORK <br /> HONE_'Y46_WORK PHONE----------. .__..�_ <br /> HOUSE LOCATION (road junction, lot number, dia`_"ces) ........ <br /> -------------------------------------------------------------- <br /> Nuabor ofpeople Hiving in house/buwtneae________ <br /> An babies lose then i W <br /> Any yr. old or expectant mothers? , <br /> Do you ovn--L- or rent...... your house? <br /> Are you the original owner?,,,,,,^,_---- <br /> : �`•. . <br /> ° if no, what is the original owner's name?_,______________,__ <br /> It you rent, what to the owner's name?........................ <br /> Owner's address ,gitM-,�, c4OYG <br /> Owner's phone number-------------------- <br /> ; <br /> Type of well: Bared_____ Drilled ­ Dug...... Jetted <br /> i <br /> Driller's name__ <br /> Approximate installation date---11kil -. rA V <br /> Well depth____:,:.Z <br /> Well screen material: Steel_____ Plastic_____ Concrete_____ <br /> Mood----- Brick------ Other--------_-_-_- <br /> f House water pipes material: Lead_____ Plastic_____ Coppe'r____ <br /> 1 Other <br /> Outside spigot? Yea_�L No <br /> Pump type: GaeElectric_---- Hand______ <br /> Do you have a voter pressure tank? YeaY\-- No---- <br /> Do you have any kind of water treatment of softener? Yes No <br /> Aa) kootl - ---- <br /> 1 <br />