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1680 ROGERS AVEtruE IVELLHEAJD ]PISPEC"x'jON (2) <br /> BLAINE SANJOSE CALIFQRrllA 951-12 <br /> TEC" SERVICES.. (1061573-7771 FAKA <br /> t r:rp� <br /> 140131 573-0559 PHONE Client L Pvt V <br /> Sde Address t s*7 s— Cou..4-ry c f Z <br /> ?1 <br /> Technician_ OSC.ow <br /> Date ti f m ca <br /> I Ltd rnr box' S Casing secUre F f2 Water standing rn wellbax7 r5 Well cap hincOOrtal7 <br /> 2 Ud bivVen? 7 Casing art level7 12a Standing above the top of casing? 16=Carr cap be pulled Iaose7= — <br /> 3 Ud halts missrrrv? 8 Debris hi►vellLroxi 12b Standing below tete top of casing7 17 Cart cap seal outwafer7 <br /> 4 Ud bolts slrrpped7 9 Wellbox is too far above grade? 12c Water even with the tap of casing? f9 Padlock prese1117 <br /> 5 Ud seaf rntact7 TO Wellbox Is loo far below grade" 13 Well rap present: 19 Padlock functrmta17 <br /> I I Wellbux is crushed(daiiiaged's 114 Well rap lound secure? <br /> E�f rcheck box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well LD Deficiency Corrective Action Taken <br /> F tole below all dellencfes that could riot be Corrected and 51111 deed to be corrected <br /> BTS 011tce 2sslgr-1s or Dale Dale <br /> Well I D Feisisting Deficiency deters Correction to asst ned corrected <br /> I <br /> r . <br />