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o <br /> B���E 1680 ROGERS AVENUE - 1'T ELL.E� l._, <br /> lt-ISPETION L. i CAST <br /> SAMJOSE CAtfl'XRWiR 35112 A <br />� TTECHSt;F3VtC1=S.� (4178)573--7771 FAX Client <br /> (408)573-0555 PHONE <br /> p <br /> Sde Address (RcA—,' <br /> TechnIC12r� <br /> Date .... <br /> i+Jo rx� <br /> 1=Lid an box? 6=Casing se=re' 12=Water standing in weflbox7 15=Well mo turrcIIorid^, <br /> 2 Lid broken? 7 Casing cut levef7 12a,standing above the top or casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts mrs3ina78 Debits in welllrox7 12b Stanomca <br /> g below the top of sing? 17 Can cap seal out water-, <br /> 4 Lid bolts stripped? 9 Weflbox is tao tar above oraae7 t2c Water even with the top of casino? 18 Padlock oresent? <br /> 5 Lid seal intact" 10 Wellbox is too far below vraoe7 13 Weil rip present? 19 Padlock luricitonal? <br /> 1 3 Welibox is a usnedldarnaoed' id Well ca-a found se—=L37 <br /> Check box If no deficiencies were found Note below denciencles you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all denencies that could not be correclec ano still need to be corrected <br /> BTS O1-l1Ce assigns or Dale Dale <br /> Well I D Persisting Deficiency deters Correction to assioned corrected <br /> I <br /> k I # <br /> i <br /> I <br />