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Date 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 />' Thank you for your cooperation <br />' 1) Name of Property Owner Phone No <br /> Address 1-1 <br />' 2) Name of Tenants c Phone No i <br /> Address l 4 4� <br /> 3) Are there wells on the property? (circle one) es no I don't know <br /> 4) Number of wells 5) Well diameter <br /> 6) Well Depth <br />' 7) Well material (circle one) PVC Plastic <br /> Steel Back/clay Other <br /> S) Date of Installation <br /> 9) Frequency of use 7` <br /> 10) What is the well used for? <br />' (circle one) rinkmg water Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES <br /> Additional Information and/or Comments NAy,4, r-� 4 <br />