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Date WELL SURVEY QUESTIONNAIRE <br /> _ r,P 4(� �t 5� ,_ <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 _R{- 1a f-lo.,j c--L_ Phone No <br /> Address z�#�1z �� 'c: _g.1 M,c\0-rEe_A <br /> 2) Name of Tenant iy Phone No I <br /> Address z4t, IZ:,.4 enA&)IL:c- A <br />' 3) Are there wells on the property) (circle one) 1es no I don't know <br /> 4) Number of wells 5) Well diameter _v` <br /> 6) Well Depth LA <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other ( <br /> S) Date of Installation t.t <br /> 9) Frequency of use <br /> 10) What is the well used fort 717 A-4 <br /> (circle one) Drinking water Agriculture Monitor groundwater IC Cher describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES O <br /> Additional Information and/or Comments <br />