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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.sigov.org/ehd <br /> _C'(11lfIP INSPECTION CHECK LIS`f <br /> dress: Perm #: ZnsecYio Dafe: <br /> 17) 10S I �m1 nJ )y� �� 9.J8'D I __71 !! <br /> 'c <br /> Parameter/StandardComments/Measuresnens/ <br /> Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes INO ❑ NA❑ _ <br /> Casing extends at least 12" above grade Yes Q No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [0 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes [2 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes 12 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [4 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [�r No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑v No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes 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 domestic supply) Yes ❑ No ❑ NA J� <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [I <br /> MAINTENANCE: - <br /> Well/Pump visible and protected from damage Yes [� No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 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 ElIf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [11 No ❑ _ <br /> OTHER: - -- <br /> Comments: <br /> i <br /> i <br /> Inspected By:—Li cs Title: <br /> te: <br /> Received By: Da <br /> nlnA('1AA C <br />