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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efephone:(209)468-3420„=ax:(209)468-3433 Web:www.sigov.orq/ehd <br /> �� ►�-�r, .F INSP :CTMA GFIECK LIST <br /> P: dress: Permit#: Inspection Date: <br /> Parameter/Standard Meets SJG Standards? OofiimenfslMeasuremerits/ <br /> Recommendations <br /> CEMENT 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 ❑ INo0 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 purnp 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 <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within T of wellhead Yes ❑ No ❑ NA [� i <br /> Adequately installed check valve or BFP device Yes ❑ No ❑ NA Ij <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA 11 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future YesNo ❑ If`no'is Selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes lNoEl <br /> OTHER: <br /> Comments. <br /> i <br /> =1rispectedOy: Title: W 5 J� <br /> Received By: Date: <br /> .. nfnA lnnAC <br />