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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186-8_Eas.._Hazelton-Aven-ue,_Stockt-o-u, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.orq/ehd MVP INSPECiTON CHECKLIST -- — - --_-- Address: 1 - L rj o -b Per if i i) 0 3-7y a8 Inspection Date: c)/ . Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes �A No ❑ NA ❑ Casing extends at least 1" above pedestal Yes V No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ _ Seal between all pipe columns and casing Yes V1 No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes (Q No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA IA SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [] No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA lid MAINTENANCE: Well/Pump visible and protected from damage Yes ,No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: . Permit drawing represents actual location of well . YesQ No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By; 0 Title: v IV"r1r1.PA4 Received By: Date: