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SAN JOAQUIN COUNTY <br /> Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone; (209)468-3420 Fax. (209)468-3433 Web:www.sigov.orq/ehd <br /> PUWIP WSPEC t ION CHECK LIST <br /> Address: Permi fnspe Pion ate: <br /> PJ, J-f�k ibot .SN C-k.i_bAJ t�1 �3 <br /> Parameter/Standard Meets 5JC Standards? Cornments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes M No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [j" No ❑ NA❑ <br /> Free of cracks/contiguous with anular seal Yes 0 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes INo ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes 9 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA W <br /> Chlorination port available and sealed properly Yes I No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes v No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes 9 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes JZ No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes P1 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected,aitach an accurate map to permit <br /> Photograph taken and attached to record Yes rrA No ❑ <br /> OTHER: — <br /> Comments: <br /> InspectedBy: S() Title: <br /> Received By: Date: <br /> Gu nonn <br /> aria tuna� <br />