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K s <br /> WELL SURVEY QUESTIONNAIRE <br /> Date _(� l(� �? ,� <br /> To whom o t 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 Phone No <br /> Address <br /> 2) Name of Tenant Phone No <br /> Address <br /> 3) Are there wells on the property) (circle one) yes no I don't know <br /> 4) Number of wells +�s Q��� 5) Well diameter U <br /> 6) Well Depth LA <br /> 7) Well material (circle one) PVC Plastic Steel Brick/claY Other t� <br /> 8) Date of Installation LA <br /> I9) Frequency of use LIA <br /> 10) What is the well used for9 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 !~� Vis cl, orl-l�� _ <br />