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"AN rOA QU I!,,] COUNTY <br /> ENVIRONIMENTAL HEALTH DEPARTMENT <br /> 1868 East HazelOnAvenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-10420 Fax.- (209)468-3433 IV'eb: mkilm.sip,ov.oEgLehd <br /> PUNAP IF1JSPECTfON CHECK LIST <br /> Pe n lion Fpfe- <br /> Address: # <br /> C�3 <br /> 3 <br /> Parameter/Standard 11fleets SJC Standards? Com mentsIlIr", sUrements), <br /> Recommendations <br /> CEMIENTP EDESTAL.: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes U No 0 NAF-1 <br /> Casing extends at least 1Z above grade Yes No El INA 1:1 <br /> Casing extends at least V above pedestal IYes No ❑ NA FI <br /> Free of cracks1contiguous.with annular seal Yes 2 INo El NA ❑ <br /> Graded to allow drainage away from casing IYes V INo ❑ JVA <br /> A141TARY SEAL: <br /> Well is sealed between pump and casing Yes k? INoF-1 I NAE1 I <br /> Seal between all pipe columns and casing Yes No F I NA ❑ <br /> ;Sounding lube/air vents sealed properly Yes ❑ No ❑ INA [V I <br /> Chlorination port available and sealed properly No [:11 NAE] I <br /> SA,110PLE TAP AND BACK]FLOIAT PREVENTION: <br /> 'Non-threaded sample tap betvveen well head and <br /> lcheck valve or within 3' of well head Yes 1\o [I NA ❑ <br /> 1dequately installed check valve or 8FP device Yes NoF-1 NAEJ <br /> lNo cross connections (ex: chemical feeders <br /> h ooked to distribution system/ag flood irrigation <br /> Jl om domestic supply) JYesEj No 0 NAF <br /> Air gap of at least 6" (same as pipe diameter) YesEl I No IR I NA <br /> FOAINITENAINGE: <br /> [�TVell/Pump visible and protected from damagesNo R INA F-1 <br /> I <br /> IiWell/Pump free from excessive vegetation +yy s -2 No 0 INAE1 I <br /> I li <br /> ATUSCELLANEOUS. <br /> Permit drawing represents actual location of well Yes No <br /> Peri -lit drawing sufficient1to locate well in future Yes 10 1 No If'no2 is selected,attach an accurate map to permit <br /> Photograph taken and attached to record v e s 1\1 oE1 <br /> 0 T HE R: <br /> --- <br /> Gai-j i-n e j n s� <br /> L <br /> inspected By: Tftle: <br /> Received By: Date: <br />