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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efc-phone;(209)468-3420 Fax:(209)468-3433 Web www.sjgov.org/ehd <br /> L INSPECTION CI-IECK LIST <br /> Address: - Permit: Inspection bate: <br /> 1��1� os 2 <br /> Parameter/Sfandard Meets Standards? Conimetits/Measurements/ <br /> Recommendations <br /> CE14EN T PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes I No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes - No INA❑ <br /> Seal between all pipe columns and casing Yes No ❑ INA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA 11 <br /> Chlorination port available and sealed properly Yes S� No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes A �NoO NA❑ i <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ INo ❑ NA 1 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ I NA❑ <br /> Weil/Pump free from excessive vegetation Yes No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ 11'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: j <br /> I <br /> VA Inspected By: 1 Title: V"� <br /> i <br /> Received By: Date: <br /> AfnA f1AA C <br />