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Date �C. WELL SURVEY QUESTIONNAIRE <br /> {p a'�.� <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 /> I 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 <br /> Phone No <br /> Address - <br /> '"ate= 1-11 �J 4s,3) Are there wells on the property9 (circle one) es no I don't know <br /> 4) Number of wells ATL� �;_i rJG 5) Well diameter <br /> 6) Well Depth A _ <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> 8) Date of Installation <br /> 9) Frequency of use <br /> 10) What is the well used for? u1 <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 rJ I tJ <br />