Laserfiche WebLink
Tfi ���To r1� [ruaT� <br /> ho <br /> WELL SURVEY QUESTIONNAIRE <br /> Date - �r �t <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 _. Y"tS [�ln� . �����,; Phone No U <br /> Address <br /> 2) Name of Tenant _��l _ __Phone No gin <br /> Address <br /> 3) Are there wells on the property) (circle one) es no I don't know <br /> 4) Number of wells f 5) Well diameter t ,k <br /> {} Well Depth LA <br />' 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br />' 8) Date of Installation t.+ <br />' 9) Frequency of use <br /> 10) What is the well used for? �_A <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 v1 <br /> Additional Information and/or Comments <br /> 1 <br />