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Date �� • WELL SURVEY QUESTIONNAIRE <br /> Co � <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 /> I 1) Name of Property OwnerSLR L(-�_a 4,� _ Phone No r 6-t v - <br /> Address <br />' 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property`) (circle one) es no I don't know <br /> 4) Number of wells 1 5) Well diameter —LA <br /> 6) Well Depth , - « �,,r �� r_ r=t•, _ca,z <br /> 7) Well material (circle one) PVC Plastic Stee Brick/clay Other <br />' 8) Date of Installation - 7;- <br /> 9) Frequency of use i .-.� <br /> t10) What is the well used fors <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 /> 1 <br />