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Date WELL SURVEY QUESTIONNAIRE <br /> Co �co �� <br /> ITowh whom 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 _Ntu lg-:` Anp-.,.3 Phone No rJo 6�iJEtq <br /> Address 2_t �! `�c�sc w„ n ave- <br /> nn A+vT'ECwQ, <br /> 2) Name of Tenant Nomgo,,,% -tN - Phone No <br /> Address 21 'as r,M r A-A a" 4 <br /> 3) Are there wells on the property9 (circle one) no I don't know <br /> 4) Number of wells 5) Well diameter �-A <br /> b) Well Depth LA <br /> 7) Well material (circle one) PVC Plastic Steel Brick/clay Othery1 <br /> 8) Date of Installation _ L�i <br /> 9) Frequency of use -T7A+ L- _ <br /> 10) What is the well used for9 <br /> (circle one) Drinking water Agriculture Monitor groundwater Other (describe above) <br /> 11) Do you have a basement with sump pump (circle one) YES 19D <br /> Additional Information and/or Comments WC-t-(. rJ cr oN E LAWN) <br /> ly(o u LTi 4-41AAlL..r nn<Zff'(*" 1 <br />