Laserfiche WebLink
' J <br /> �^'{I�� <br /> 1 <br /> WELL SURVEY QUESTIONNAIRE <br /> Date -G i i `�1,5 <br /> To whom it may concern <br /> We would appreciate your help by completing the following questionnaire regarding the existence <br /> of wells on your property This information will be provided to Public Health Services of San <br /> Joaquin County Please fill out the survey to the best of your knowledge, even if you don't have <br /> a well Should you have any questions, contact Gary Rogers (Remedy, Inc ) at (510) 791-7157 <br /> Thank you for your cooperation <br /> 1) blame of Property Owner /�,R,�cr Phone No Nom_ <br /> Address ? ti n" <br /> 2) Name of Tenant Phone No <br /> Address =q3 <br /> 3) Are there wells on the property9 (circle one) es no I don't know <br /> 4) Number of wells Cy 5) Well diameter �-A <br /> 6) Well Depth <br /> 7) Well material (circle one) PVC Plastic tee Brick/clay Other <br /> S) Date of Installation U <br /> 9) Frequency of use <br /> 10) What is the well used fort <br /> (circle one) Drinking water Agriculture Monitor groundwater (describe above) <br /> E11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments -7 c . <br />