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Basic Information
Property Owner Name
Your answer
Street Address
Your answer
City / State / Zip
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Is this a rental unit?
What is the water source for your home?
Your answer
If you have a private well, what is the depth (in feet)?
Your answer
If you have a well, do you use it for drinking water?
If you have a private water well, has it been tested?
If yes, who tested your water well?
Do you have a copy of your water tests?
Do you treat your water?
If yes, what type of water treatment?
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