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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> CftnL-CE1EVRON*9.4054 Inspection date: 3-2jpf 1 <br /> Site address 2103 Counuy Club Blvd. Inspected by: f-fT <br /> Stockton,CA BTS Event# 9'? AL49 -'11 <br /> 1.Lid on the box? Yes No S. Water standing in the well box? 7. Can cap be pulled loose? <br /> 2.Lid whole? 5a.Standing above well top? 8. Can cap seal out water? <br /> 8.Lid secure? Sb. Standing below well top? 9. Padlock present? <br /> 4.Lid seal Intact? 5c. Water even with top of well cap? 10.Padlock found locked? <br /> 6. Wen capiplug present? 11.Padlock functional? <br /> Q Check box if no delklences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> N^Vftl- o" Lq OW9, <br /> W-1 a D&k 1,f Lai,-. <br /> i'r1 g v4 c1 " <br /> 1 <br /> Note below all deficienaes that could not be corrected and still need to be corrected. <br /> 8T8Office aNpp$or Date Date <br /> Well I.D. Peralsong Deflcienty dolens Gortiadion to: assigned cwncted <br /> OM c <br /> 1A Ur4l ow+w <br /> � br <br /> ytio �{,qU <br /> x a k <br /> y ( A) Office review and assignments made by data <br /> Blaine Tech Services, Inc. File WELLCHK.s <br /> S <br /> E/E "3JVd ILLL ELS 9019 3331AU33 H331 3AIIVZH EE I1 NOW L6 . 90 "d39 <br />