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Date ��![3��{53 WELL SURVEY QUESTIONNAIRE <br /> Cd <br /> I <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 /> I1) Name of Property Owner ialla,_.")w, fc�C �t� inane No ,�`--� <br /> Address _a a 4e - <br /> 2) Name of Tenant 1i�'1�. �, ��� Phone No <br /> Address <br /> I3) Are there wells on the property? (circle one) � ' no I don't know <br /> 4) Number of wells ' U'1 41--7 5) Well diameter n t ,i- ;c t <br /> 6) Well Depth r lU` ^ i_AJP. t— <br /> 7) Well material (circle one) PVC Plastic ('Steel Other <br /> I8) Date of Installation 1_12+ - 0 L� <br /> 9) Frequency of use <br /> 10) What is the well used fort <br /> (circle one�. Drinking water Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES NO~` <br /> Additional Information and/or Comments <br /> I <br />