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I i <br /> V I �TT[F <br /> r° r <br /> 1680 ROGEAS AVENUE WELLHEAD INSPE&ION CHCECK]LIS''I' F� <br /> BLAINE SA JQSE4 CALIFORNIA 45112 <br /> Tech s�tvt •a (4Datw53- 'I AX <br /> , Client <br /> � (analtWER <br /> s'�;o <br /> LJ Site Address I�4c�h�ctf - <br /> z APP Q 12000 Technician 14C-1 . <br /> ENVIRONMENTAL HEALTH Date 3— (3 <br /> JVC, $ PERMIT/ SERVICES <br /> 1-Lid on box? 6-Casing secure? 12--Water standing in wellbox7 15-Well cap functional? - <br /> 2 Lid broken? 7 Casing aft level? 12a.standing above the tap of casing? 16 Can cap be pulled loose? <br /> 3 Lid baits missing? 8 Debns in weffbox7 12b Standing below the top of rastng7 17 Can cap seal out w2ter7r <br /> 4 Ltd bolts stripped? _ 9 Weflbox is too far above grade? 12c Water even with the top of casino 19 Padlock present? <br /> 5-Lid seal tntact7— — 10-Welibox is too far below grade— —' 13—Well cap present?—"— 19-Padlock functronal?-- <br /> 1 t Weffbox is crushedidamaged? 14 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficien2y Corrective Action Taken <br /> ti <br /> Note below aff deffencres that could not be correcled and still need to be corrected <br /> BTS Office assigns or Dale Dale <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br /> SUNorJF=t L,*_ w e /-o,,k; t <br /> W_-2- <br /> +.� + <br />