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1 <br /> WELL SURVEY QUESTIONNAIRE <br /> Date G 2> <br /> To whom o t 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 M-, `T4FFPhone No <br /> Address o <br /> 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property? (circle one) es no I don't know <br /> 4) Number of wells 5) Well diameter Lel <br /> 5) Well Depth <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> S) Date of Installation lit <br /> 9) Frequency of use <br /> 10) What is the well used for? — � <br /> i (circle one) `Drinking water: Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES �O <br /> Additional Information and/or Comments <br /> I <br />