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� G <br /> WELL SURVEY QUESTIONNAIRE <br /> Date (o 115 9 43 <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 Tenant -k-c---r,3 "C>t� Phone No DoT cs, •r .!__ <br /> Address ��ZQ �.,g�o .,j 04-j�M,,It <br /> 3) Are there wells on the ) Y <br /> ert ro 7 (circle one es o I don't know <br /> p p Y <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 /> IS) Date of Installation <br /> 9) Frequency of use <br /> 10) What is the well used for) <br /> (circle one) Drinking water 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 /> I <br />