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i <br /> WELL SURVEY QUESTIONNAIRE <br /> Date '::-A`5 <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 u,r.�RPhone No <br /> Address <br />' 2) Name of Tenant Phone No <br /> Address 2Zb2 �o>c Z „ +v��,,v-x',-c-A <br />' 3) Are there wells on the property? (circle one) es no I don't know <br /> 4) Number of wells f 7 s c�T Q 5) Well diameter c-t <br /> 6) Well Depth (- A <br />' 7) Well material (circle one) PVC Plastic Steel Brick/clay Other �-A <br />' 8) Date of Installation <br /> 9) Frequency of use <br /> 10) What is the well used fors U <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 Comments Us 5u 0, Cnj <br /> 1 <br />