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lsaa 13a�� _ JEIYEfE NVELL�I " ,-JPEC7nON CHMCKL`I,9T <br /> ELAINE _SAM.IoSE,CAUFORMIA 95112 <br /> TECH SESVIGES (408)573-7771 FAX <br /> 1408)573-0555 PHONE f - <br /> .r7aB P1ddi'e55_ IM"'j j N, E"4m <br /> z Technlcfan� To��. ��tni _-- <br /> Date <br /> z 12 _water s=ndrng to well4ox?� 1�=Well can lraa�onat�� <br /> 1 LtTornbox, <br /> �- <br /> I z7 , asrng r�tt 1eVel; 120 S ntfino above the top of rasing? f6 Can capbcLpu!!ed loas27 <br /> 113 <br /> 3 Ltd bolts mtsstna 7 8 Debits to wellbox7 12b Sm6ina below the top of c:asma 17 Can cap seal out water? <br /> 4 Ud bolts Strtppe07 9 Welibox is too Far above ar2de7 12C water even with the top of casmc;7 18 Padlock present? <br /> 5 Ltd seal intact? 10 welfbox Is too far belo>v grade? 13 Well cap present? 19 Padlock final? <br /> 11 Wellbox is cntshed/demaoed7 114 'Nell cap Lound secure? <br /> 0 Check box if no deficiencies were found Note befovll deficiencies you were able to coarct <br /> Well t D Deficiency Corrective Action Takers <br /> M w• W �ttl"' t� <br /> Note below ail deflenctes that could not be corrected and still need to be corrected <br /> BTS Office assigns or Dale Date <br /> Well 1 D PerSISim❑ DeticlenGV defers Correction to assigned corrected <br /> - t✓clI <br /> I <br />