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Date WELL SURVEY QUESTIONNAIRE <br /> Co +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 />' 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 Phone No <br /> Address <br />' 2) Name of Tenant Phone No I <br /> Address ;nA A "T C <br />' 3) Are there wells on the property9 (circle one) es no I don't know <br /> 4) Number of wells — aP.l5) Well diameter �-A <br /> 6) Well Depth Via__ <br />' 7) Well material (circle one) PVC Plastic Steel Brick/clay Other _-t <br />' 8) Date of Installation LA <br />' 9) Frequency of use <br /> 10) What is the well used fors <br />' (circle one) Drinking water Agriculture Monitor groundwaterther describe above) <br />' 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments <br />' Zr->- -Zs 1 -� <br /> 1 <br />