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SAN jOAQUIN COUI',,ITY <br /> ENVIRONIMENTAi-HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 l=ax: (209) 468-3433 1414eb:vArvw.sjqov.org/ehd <br /> - F'UM1P_1NSP..ECT1ON CHECK LIST <br /> ��� - --$ S-Address, npecate: <br /> yon g <br /> COMAL ffbLLD W PPIKA-Cy -1 K-0 0-75--7 0�_ , ?(I y 'I I Is�_(( <br /> — Parameter/Standard Meets SJC Standards? I Cornments/AfleaSUremeiiisl <br /> Recommendatioiis <br /> C EUViENTPEDESTAL: <br /> Dimensions of surface seal (2'x2'x4-` minimum) Yes 2 NoEl NAEJ <br /> Casing extends at least 12" above grade Yes [2 No F-1 INA ❑ <br /> Casing extends afleast Vabove pedestal Y e s FA IN o ❑ NAE] <br /> Free of'cracks/contiguous with annular seal Yes [j] NoFj NA ❑ <br /> Graded to allow drainage away from casing Yes No [:] NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between PUMID and casing Yes No <br /> F NAE] <br /> Seal between all pipe columns and casing Yes No 0 NA <br /> iSounding tube/air vents sealed properly IYes 0 NoE] NA LEY <br /> 'Chlorination port available and sealed properly I Yes ZZ NoE:1 NA [:1 <br /> SAMPLE TAP AND BACKFLOW PREVENTION. <br /> Mon-threaded sample tap between well head andl <br /> i check valve or within 3' of well head Yes W1 No ❑ INAE] <br /> 1 <br /> Adequately installed check valve or BFP device IYes V NoE:1 I NA E] <br /> INIo cross connections (ex: chemical feeders <br /> 1hooked to distribution system/ag flood irrigation <br /> Ij <br /> F.— <br /> ;from domestic supply) YesEl No El NA <br /> jAir gap of at least 6" (same as pipe diameter) YesF_ <br /> j No L__1 INA N <br /> 1MAINTENANCE: <br /> ,VVell/Punip visible and protected from damage I Yes Q INo 0 NA [_1 I it <br /> Well/Pump free from excessive.vegetation I.Yes 2 INoO NAE] I <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well —Yes No ❑ <br /> 'Permit drawing sufflicientto locate well in future Yes NoE:1 It'neis selected,aftach an accurate map to permit <br /> jPhotograph taken and attached to record Yes No ❑ <br /> 0 T H LE R: <br /> Co rn m en-s, Ii <br /> t le C( <br /> II <br /> ii <br /> '!aspected By: ax. Title: <br /> Received By: I Date: <br /> CU A'�rin <br />