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� `b2`lra a2�c-uT A1� <br /> 41 , <br /> ll <br /> WELL SURVEY QUESTIONNAIRE <br /> Date <br /> To <br /> 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' N?Tr+e of Property Owner _ C- I" Phone No �24� <br /> Address L L. �Z/ E-L� n� 2�4 <br /> 2) Name of Tenant Phone No <br /> Address <br />' 3) Are there wells on the property? (circle one), yes no I don't know <br /> 4) Number of wells � C2 5) Well diameter <br /> 6) Wel] Depth <br /> 7) Well material (circle one) PVC Plastic eel Brick/clay Other <br />' 8) Date of Installation <br /> 9) Frequency of useC'C�'L' L ` 1 -C7-' <br /> 10 What is the well used for? <br /> tcircieunej ilnnxing water '�►grlculture Monitor groundwater Other (describe above) �J- <br />' 11) Do you have a basement with sump pump (circle one) YESNO I� <br /> Additional Information and/or omments <br />