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Date G I(a 4 WELL SURVEY QUESTIONNAIRE <br /> 1 8 <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 Ula, n�A+-t N�_;ha R Phone No / <br /> Address gwpSybui_ twe Aj rg,-�. <br />' 2) Name of Tenant / Phone No / <br /> Address ­` <br />' 3) Are there wells on the property9 (circle one) 6iD no I don't know <br /> 4) Number of wells 5) Well diameter L-A <br /> 6) Well Depth LA <br /> 7) Well material (circle one) PVC PlasticSteel N Brick/clay Other <br /> �� Y <br />' 8) Date of Installation LA <br />' 9) Frequency of use -T <br /> 10) What is the well used for? C1Cr.1L t�.��. �s�0(<_ J k <br />' (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 CommentsET-Z. <br />