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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fox: (209) 468-3433 Web: www.sigov.orcl/ehd PI IMP INSPECTION CHECK LIST Address: 3M ��7/ Y,� A -CA -01 Y V PSK �i61 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes INo ❑ 1 NA ❑ Graded to allow drainage away from casing I Yes U1 I No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes [❑i No ❑ NA ❑ Sounding tube/air vents sealed properly Yes KZ No ❑ NA ❑ Chlorination port available and sealed properly IYes ❑ No ❑ NA f Yi SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and ❑ ❑ NAV check valve or within 3' of well head Yes No Adequately installed check valve or BFP device Yes F�r 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 MAINTENANCE: Weil/Pump visible and protected from damage Yes No ❑ lNo NA ❑ Well/Pump free from excessive vegetation Yes LZ ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes V No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If 'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: jJ�f Received By: Date: