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1690 ROGERS AVENUE _ WELLBE" INSPECTI18T <br /> � <br /> SAN JOSE,CAU FO 46112 t 4. <br /> BLAINEE LI <br /> TECH SERVICES (408)573,7771 FAX Client y� s � <br /> (400)573-0555 PHONE <br /> r Site Addres <br /> ,f <br /> Technician Ifg <br /> Date 2-M <br /> JVD f <br /> J � <br /> 1 bri on box? 6 casing secure? 12. Water standing in weflbox? 115 Well cap functional? <br /> 2 Ud broken? 17 Casing cut level? 122.Standing above the top of casr 4g? 16 Can cap be pulled loose? <br /> 3 Ud bolts missing? 8 Debris m wellbox? 12b 5tand'mg below the lop of casrr'g7 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wefibox is too far above grade? 12c Water even widr die top of casng? f8 Padlock present? <br /> 5 Lid seat[nlact7 10 Welfbox m too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is cnmhedtdamaged? 114 Well cap found secure? I <br /> 1 I <br /> , 3 <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct. <br /> Well l D. Deficiency_ Corrective Action Taken i <br /> L c s t 0, ki 0"Z <br /> s � 3 <br /> l <br /> ,2 <br /> i <br /> 4 � <br /> s t <br /> t� <br /> Note below all defieiycies that could not be corrected and still need to be corrected <br /> BTS Office assigns ars Date Date <br /> Well 10 , Persisting Deficieng defers Correction to '1 ass ned corrected <br /> / f <br /> W~�✓ Yin <br /> til <br /> 1 <br /> t <br />