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1 , <br /> WELL SURVEY QUESTIONNAIRE <br /> Date _L� �y c+,�, <br /> To <br /> 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) Name of Property Owner A,6 o ,`Phone No k— 0 <br /> Address <br />' 2) Name of Tenant tMv r t�� - �_ Phone No _ _� Cs,,Qe-rj <br /> Address <br /> 3) Are there wells on the property9 (circle one) yes no I don't know <br /> 4) Number of wells 5) Well diameter _ l_.1 <br /> 6) Well Depth LA <br />' 7) Well material (circle one) PVC Plastic tee/ Brick/clay Other = <br /> 8) Date of Installation 1.1 <br /> 9) Frequency of use za I c2' <br /> 10) What is the well used fors <br /> (circle one) ' rmk!n waters Agriculture Monitor groundwater Oi& escnbe above) <br /> 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Commentscam �� --, ,�rx_r L 6-- <br /> 1 <br />