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J <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Chern Sde #r Insceciion Cate <br /> Site addr Equiva 98996189 Inspected by <br /> 6131 PACIFIC AVE <br /> STOCKTON BTS Event <br /> 1 Lid an the box? Yes Na 5 Water standing in the well bcx? 7 Can cap be pulled loose? <br /> 2 Lid whole? Sa Stanaing above well top? 8 Can Can seal out wate,? <br /> 3 Lid secure? So Stanoing below well top? 9 Fadlock present? <br /> 4 Lid seal intact? 5 c Water even with top of well cao? 10 Padlock found locked? <br /> 6. Well cap/plug present? 11 Fadlock functional? <br /> Check box if no defic:ences were found Note below aeficienc-es you were able to correct <br /> Well 1.1) Deficiency Corrective Action Taken <br /> I I <br /> I I i <br /> l I <br /> ! I <br /> Ii <br /> � j I <br /> I � <br /> I I <br /> I I <br /> Note below all dericiences that coula not be corrected and still neee to be corrected <br /> BTS Offim assigns or Date Date <br /> Well J.D. Persisting Defc:ency aefers Correction to: assigned corremed <br /> I I <br /> * L <br /> i <br /> I I I <br /> I I i i <br /> I <br /> I <br /> Office review anc ass,gnmeirs made by _ oats <br />