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cv- VED <br /> Nov � z X002 �� <br /> October 28,2002 <br /> Dear Resident <br /> The following is an independent public health questionnaire to determine if any basements or rnumcipal, domestic, <br /> or irrigation wells exist near the intersection of Moreland Court and Hammer Lane, Stockton, California The San <br /> Joaquin County Public Health Services (SJCPHS) is requesting that we identify these features in the area as part of <br /> an ongoing environmental investigation <br /> Please fill out the following information to the best of your knowledge If you do not know, lust mark it <br /> "UNKNOWN" Even if there is no well or basement at the address hsted, please complete item I and return the <br /> survey Should you have any questions, please contact the Cambria Environmental Technology, Inc project <br /> manager listed below or Harlin Knoll at the SJCPHS at(209)468-3442 Tlus information can be submitted by mail, <br /> by facsiimle or verbally by phone Thank you for your cooperation <br /> CAMBRIA ENVIRONMENTAL TECHNOLOGY,INC <br /> Aubrey Cool <br /> Project Manager <br /> Phone (510)420-3336 Fax (510)420-9170 <br /> P O Box 259 <br /> Sonoma,California 95476 <br /> I <br /> (1) PROPERTY ADDRESS LW y S "17rc �'t OF 5T0c <br /> OWNER NAME Tt'rI t1 it �"t� U SGt_ DAYTIME PHONE <br /> TENANT NAME (if not owner) DAYTIME PRONE <br /> (2)Are there any wells at the address listed in item 1 (circle one) <br /> YES <br /> UNKN0 W N NO <br /> (3)Are there any wells in the vicinity of the address listed in item 1 (circle one) <br /> YES UNKNOWN NO <br /> (4)Are there any abandoned wells at the address listed in item I (circle one) YES UNKNOWN NO <br /> Comments <br /> (5)Are there any basements at the address listed in item I (circle one) YES UNKNOWN NO <br /> (6)Is the residence at the address listed in item 1 on city water(circle one) YES NO <br /> If you answered"YES"to 2 or 3 above,please provide the following details,if possible If there is more than one well,please <br /> indicate which well you are describing <br /> WELL ADDRESS S�v/ D ti WELL OWNER K(J�( '1�0 U56v <br /> WELL WATER USE lr [[k el FREQUENCY OF USE I pC <br /> WELL DIAMETER / h[�rl WELL DEPTH i <br /> WELL MATERIAL (circle one) PVC plastic steel bncldclay other f <br /> SCREENED INTERVALS)OR PUMP DEPTH <br /> /� c� a /6L Lc 1taC„11--f <br /> DATE OF INSTALLATION y U n2 AS ! tt l 6 f ! J <br /> OTHER INFORMATION O k I �� I'! 0 <br /> y i i 6953 <br />