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Date WELL SURVEY QUESTIONNAIRE <br /> (o lCo �� <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 Mu H-R,Ag,-j , � Phone No N Czrt�lE N <br /> Address + r� rsfr <br /> 2) Name of Tenant NIAM t-9-cm S Phone No kksT csr vim/ <br /> Address 2210 Yrs>; --M r*y. c 4- <br /> 3) Are there wells on the property) (circle one) es no I don't know <br /> 4) Number of wells If C- 5) Well diameter �-A <br /> 6) Well Depth LA <br />' 7) Well material (circle one) PVC Plastic Steel Brick/clay Other -LA- <br /> 8) <br /> iS) Date of Installation LA <br />' 9) Frequency of use -T--,,A, L-'-' <br /> 10) What is the well used for? <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 __. _ <br />