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Date to r WELL SURVEY QUESTIONNAIRE <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 /> I1) Name of Property Owner -7-),byJ rJ i Phone No ro cs, (3-1 ,j irk <br /> Address Z -' _ Pt vinA,.r-JT <br /> 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property? (circle one) ryes no I don't know <br /> 4) Number of wells y 5) Well diameter <br /> 6) Well Depth LA <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> $) Date of Installation <br /> E9) Frequency of use <br /> 10) What is the well used fors <br /> (circle one) Drinking waterer 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 />