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Date Co 1(c 9 8) WELL SURVEY QUESTIONNAIRE <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 s v_L L - Phone No <br /> Address <br /> ?) Name of Tenant TATs-,l -,Apc- ' Eo -?_ Phone No / <br /> Address - <br /> q � A ,;-C v� 1M,, - <br /> 3) Are there wells on the property) (circle one) es no I don't know <br /> 4) Number of wells 5) Well diameter _ <br /> 6) Well Depth <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> S) Date of Installation <br /> 9) Frequency of use _T:,(_ `t <br /> 10) What is the welI used fors ry f <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 />