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Date tri 1 to Ink Fn WELL SURVEY QUESTIONNAIRE <br />' <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 /> IThank you for your cooperation <br /> I1) Name of Property Owner / _ Phone No r' <br /> Address <br /> 2) Name of Tenant .c -+, --n,y\i Phone No <br /> Address 7-o(,z AA*ev-2�` <br /> 3) Are there wells on the property) (circle one) es no I don't know <br /> 4) Number of wells ��►� - 5) Well diameter (—A <br /> 6) Well Depth (A <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> S) Date of Installation L.A <br /> 9) Frequency of use +-P <br /> 10) What is the well used for? <br /> (circle one) Drinking water Agriculture Monitor groundwaterthen (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments <br />