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Date � WELL SURVEY QUESTIONNAIRE <br />' ](o� q�, <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) Name of Property Owner Phone No / <br /> Address If <br /> 2) Name of Tenant --�zjjPhone No <br /> Address o < a <br /> 3) Are there wells on the property? (circle one) (E) no I don't know <br /> 4) Number of wells 5) Well diameter �,k <br /> 6) Well Depth LA <br /> 7) Well material circle one PVC Plastic 1 <br /> ( ) Steel Brick/clay Other <br /> 8) Date of Installation <br /> 9) Frequency of use <br /> 10) What is the well used for9 7T),f CNK,t n1c <br /> (circle one) ranking waterer Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments _ �_ <br />