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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Inspection date: <br /> Equiva 98996181 <br /> Site address_ 2494 FREMONT STREET Inspected by: f <br /> STOCKTON <br /> BTS Event# q9 !) <br /> [3. <br /> Lid on the box? Yes No 5. Water standing in the well box? 7. Can cap be pulled loose? <br /> Lid whole? 5a. Standing above well top? 8. Can cap seal out water? <br /> Lid secure? 5b. 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. Well capoug present? 11. Padlock functional? <br /> dCheck box if no deficiences were found. Note below deficiencies you were able to <br /> correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all deficiences that could not be corrected and still need to be corrected. <br /> Well I.D. Persisting Deficient BTS Office assigns or Date Date <br /> Y defers Correction to: assigned corrected <br /> r <br /> Office review and assignments made by <br /> dale <br /> Blaine Tech Services, Inc. t=ile WELLCHK.s <br />