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3 <br /> SAN�iOAGFUIiq f'0UNT1' <br /> ENVIRONIVENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:wvAr✓.sigov.org/ehd <br /> PUPO_P WFIS���EC TION C1.HECK LIST _1_ _ p <br /> Address: ^I ��"DE CT J Mck- v� —_-- s�f 6�oZ� I isZItion rl�e <br /> 'V 8 <br /> I CommentslMeasurements/ <br /> ParameterlStandard Mees SJC Standards? 1 <br /> Recommendations i <br /> CEMENT PEDESTAL: m p <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [V No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes [V 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 /> SAI IITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> 1 <br /> jSea] between all pipe columns and casing Yes 9 No ❑ NA ❑ j <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [V <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ j <br /> SAIMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and i <br /> check valve or within 3' of well head Yes No ❑ NA ❑ <br /> Adequately installed check valve or PFP device Yes Q( No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> !hooked to distribution system/ag flood irrigation I! <br /> "om domestic supply) Yes El No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [�Z f <br /> MAINTENANCE: <br /> !Well/Pump visible and protected from damage Yes [�j No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation IYes V I No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q No ❑ I <br /> Permit drawing sufficient to locate well in future Yes j No ❑ if`no'is selected, aft2ch an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ ! <br /> C�T IiEI?: <br /> CaIYltYl mfs: <br /> � � r <br /> Ii - <br /> i <br /> i <br /> I i <br /> inspected By: S Q I Title: A-S)/J/l ei.� <br /> i <br /> U Received By: I Date: <br /> r_u r^nn <br />