Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />168 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Tefephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgiehd <br />1911rIVIP INSPECTION CHECK LIST _ <br />'Address: <br />\ 'VI • Vo'n , (..‘)., ci 51.--k-Q <br />Permit#: <br />NO c,o, bt-) 42. ok•o`t <br />Inspection Date: <br />651.301 )1 . <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x27x4." minimum) Yes I I No I I NA jJ <br />Casing extends at least 12" above grade Yes yi No NA n _ • <br />Casing extends at least 1" above pedestal Yes E No I I NA Ni • <br />Free of cracks/contiguous with annular seal Yes E No I I NA r— ' <br />Graded to allow drainage away from casing Yes No I I NA rj <br />SANITARY SEAL: • <br />Well is sealed i - ,..,,-. s • Yes No fl NA <br />Seal between all pipe columns and casing Yes Rr No n NA r _ <br />Sounding tube/air vents Sealed properly - Yes I I No I I NA Al. 1 <br />Chlorination port available and sealed properly Yes n No fl 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 H No NA <br />Adequately installed check valve or BFP device Yes ri No n NA L 1l• <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes No NA A <br />Air gap of at least 6" (same as pipe diameter) Yes -1 No I I NA g . <br />MAINTENANCE: 1 . <br />Well/Pump visible and protected from damage Yes INJ‘ No _ NA E 1 <br />Well/Pump free from excessive vegetation Yes I' No FI NA) • I <br />MISCELLANEOUS: I <br />Permit drawing represents actual location of well Yes No I <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No n <br />Photograph taken and attached to record Yes No E <br />OTHER: <br />Comments: <br />• <br />\ <br />. Alk . <br />Inspected By: \ \‘ \ kt Title: CIA C 4.)(-,' • . <br />Received By: Date: <br />fltfld in /14