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Date WELL SURVEY QUESTIONNAIRE <br /> �� 1(c� Ct <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) Name of Property Owner ���,,,)��; ��c ti�CR Phone No <br /> Address <br /> 2) Name of Tenant _�s�cz Phone No ate- 25z3 - cz i <br /> Address <br /> 3) Are there wells on the property (circle one) es no I don't know <br /> 4) Number of wellsc�1i� 5) Well diameter —C-1A <br /> 6) Well Depth rpt <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other <br /> 8) Date of Installation L-A <br /> 9) Frequency of use T- <br /> 10) What is the well used for`► <br /> (circle one) 6inkin water Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES qz-7— <br /> Additional Information and/or Comments MLA L-1 ;• ,, ��L- <br />