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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.orq/ehd <br /> PUWIP INSPECTION CHECK LIST <br /> Address: Perm _ 71nsp-`=t1onDate: <br /> ONS I E • SOu`T�+LQ-D m I„� oo 3��5o��J� <br /> Parameter/Standard Meets SJC Standards? comments/Measurements] <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes ® No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes 2 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 /> SANITARY SEAL: <br /> V1/eII is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ® No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes L4 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 ® No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dornestic supply) Yes ❑ No INA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA EY <br /> [ZIlIPumpMAINTENANCE: <br /> visible and protected from damage Yes 2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes JZ No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 21 No ❑ <br /> OTHER: <br /> Comments: - ----- — . <br /> ok <br /> I ;J <br /> Inspected By: Aa.. �S`0 — ---- - - -- -- Title: . 4i jifiA^7- j <br /> Received By: Date: V <br /> Mu .)nn <br /> a� rnar_ <br />