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Date C -p I ca 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 »o Phone No <br /> Address / C57 �1,, <br />' 2) Name of Tenant C-z�N, eT Phone No <br /> Address NJE nnA, TCCA <br />' 3) Are there wells on the property? (circle one) Te no 1 don't know <br /> 4) Number of wells d,i5) Well diameter <br /> 6) Well Depth LA <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Other _�-A <br /> 8) Date of Installation L-A <br /> 9) Frequency of use 1 <br /> 10) What is the well used for <br />' (circle one) rinking water Agriculture Monitor groundwater Other (describe above) <br />' 11) Do you have a basement with sump pump (circle one) YES �O <br /> Additional Information and/or Comments / _ <br />