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12- 2 i <br /> Date Ca �� <br /> A v G <br /> WELL SURVEY QUESTIONNAIRE <br /> �CQ <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 P►oper y Gwiier {,�c4d�l }� s�i� Phone No R23-1S7 <br /> Address n7 <br /> t2) Name of Tenant 1L F Phone No <br /> Address <br />' 3) Are there wells on the property9 (circle one) es no I don't know <br /> 4) Number of wells j 5) Well diameter <br /> 6) Well DepthF-i <br /> j� f� <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br />' 8) Date of Installation <br />' 9) Frequency of use u> <br /> 10) What is the well used for) <br /> (circle one) Drinking wate - 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 /> 1 <br />