Laserfiche WebLink
SAN JO/-`OUIN ("'OUFITY <br /> EfwIRONIVIENTAI_HEALTH DEPARTMENT <br /> 1368 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> T elepha't e: (209)468-3420 l=ax: (209) 468_3433 r. 6b:vArvw.sjgov.org/ehd <br /> f,ddress: Perm' Inspe ao ate <br /> 13MC) E. COLLA " 2f, A CA-mPb I w o®38a� 6 12�o�`�S <br /> PS Comments/Ilrleasurements/ <br /> arameter/Siandard Meets AJC Standards? <br /> Recommendations <br /> EMENT' PEDESTAL: �I <br /> !Dimensions of surface seal (2'x2'x4" minimum) Yes Fn6 No ❑ INA❑ <br /> I' <br /> Casing extends at least 12" above grade Yes W No ❑ I NA ❑ <br /> g 1 1 IYes [i' No <br /> ICasin expends a�� least 1' above pedestal ❑ INA ❑ <br /> !Free of cracks1con'Liguous with annular seal jYesW No ❑ NA❑ I � <br /> `Graded to allow drainage away from casing IYes Y No ❑ NA ❑ <br /> SANITARY SEAL: <br /> SAL: <br /> Pell is sealed between pump and casing Yes ❑v' No ❑ NA ❑ <br /> 'Seal between all pipe columns and casing Yes �']No ❑ NA ❑ <br /> ;Sounding tube/air vents sealed properly Yes ❑ No ❑ NA L-� <br /> (Chlorination port available and sealed properly YesjZ INo ❑ NA ❑ <br /> i <br /> lSArVlPLE TAP AND BACKFE_C;lIN PREVEIETION. <br /> Mon-threaded sample tap between well head and I-N <br /> cl eck valve or within 3' of well head Yes o ❑ INA ❑ <br /> Adequately installed check valve or PFP device Yes FNo ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> !hooked to distribution systemfag flood irrigation <br /> �firom domestic supply) Yes ❑ No ❑ NA F,� i <br /> �lAir gap of at least &' (same as pipe diameter) IYes ❑ INo ❑ NA W <br /> ft AINTENANCE: Il <br /> Tell/Pump visible and protected from damage IYesRj No ❑ NA❑ Iy <br /> lAfelliPump free from excessive vegetation IYes 2 No ❑ NA ❑ <br /> If1Ii1SCELLANEOU-S- <br /> Permit drawing represents actual location of well Yes yi INo ❑ j <br /> i Permit drawing SUf f!dent to locate well in future Yes © No ❑ If'no'is selected,a«ach an accurate map to permit <br /> I g I <br /> IPhotograph'Laken and attached to record Yes Q INo ❑ <br /> OTHI-'R: I1� <br /> Col�,rtlertts: ' <br /> I <br /> i <br /> i <br /> I' <br /> I <br /> Ij Ii <br /> i; <br /> N <br /> u <br /> !inspected i3v: Ol.k I7iile: i A-(I <br /> 4-s•.t <br /> ll Received <br /> By: Date: <br /> nraa 111)1)4 r <br />