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Date WELL SURVEY QUESTIONNAIRE <br /> 1 <br /> ' �I(n•Gl8 <br /> To whom it may concern <br /> o y <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 _���T� ,w E RJ _ Phone No NxSTe,-i J j�NJ <br /> Address n _ <br /> 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property9 (circle one) yes no don't know <br /> 4) Number of wells 5) Well diameter / <br /> 6) Well Depth <br /> 7 Well material circle one PVC Plastic Steel Brick/clay Other / <br /> { ) y <br /> 8) Date of Installation <br /> 9) Frequency of use / <br /> 10) What is the well used fort <br /> i (circle one) Drinking water Agriculture Monitor groundwater Other (describe above) <br />' 11) Do you have a basement with sump pump (circle one) YES NO <br /> Additional Information and/or Comments !A n tj tc t rbL urs t t <br /> S <br /> l" <br />