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i f9 <br /> WELL SURVEY QUESTIONNAIRE <br /> Date <br />' <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 LA Phone No u <br /> Address U1 <br />' 2) Name of Tenant ^ 1 ^�F Tr;� c Phone No LZ<[ —Zq <br /> Address 4`it�� �,, , &A1rNr-3TF,4g <br />' 3) Are there wells on the pro ert )circle one es n �— <br /> p Y ( 0 1 don't know <br /> 4) Number of wells ON„ 5) Well diameter <br /> 6) Well Depth <br />' 7) Well material (circle one) PVC Plastic <br /> tee/ Brick/clay Other <br />' 8) Date of Installation C'A <br />' 9) Frequency of use <br /> 10) What is the well used for? _:1--TZ <br /> (circle one) Drinking water Agriculture Monitor roup <br /> dwater t�her (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES V� <br /> Additional Information and/or Comments <br />