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3 <br /> WELL SURVEY QUESTIONNAIRE <br /> Date , <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 <br /> 2) Name of TenantAA �' . - 4' Phone No a- q <br /> Address �_G�� �'� ,�1 t J+� 1rtll 1'Yr <br /> 3) Are there wells on the property) (circle one) es no I don't know <br /> 4) Number of wells c7 .3L� 5) Well diameter .UI <br /> 6) Well Depth <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> 8) Date of Installation LA <br /> 9) Frequency of use <br /> 10) What is the well used for9 <br /> (circle one) Drinking water Agriculture Monitor groundwater <jthey escribe above) <br /> I11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments �; / �� �C✓t✓ <br /> pr �X,n,STs �,w r- i4 Cn,0 _� <br />