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S/-1..N1,-.'iOAQzU1h1. GOUNITY <br /> ENVIRONIMEiaim-HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Vifeb:w\vVv-sj.Qoy.orQ/ehd <br /> PURAP 111NISPECIFION CHECK LIST <br /> F!Address- <br /> �1ns1-,-e/t'ion Date, <br /> Sq 9 S W40i P�D 39 403 17- Z- <br /> Pai-arneterlStandard Meets SJC Standai-ds? Comm entslAfleaSUremell LS1 <br /> Recommendations <br /> CEMIENTPEDESTAL' <br /> Dimensions of surface seal (2'32'x4` minimum) Yes Q No Fj NAE1 <br /> Casing extends.at least 12" above grade Yes V I NoEj NA 0 <br /> Casing extends at least 1"above pedestal YesIleo [1 INA [:] <br /> Free of cracks/contiguous.with annular seal IYes W I NoEl INA F] Ii <br /> Graded to allow drainage away from casing IYes &4 INoE1 INA D <br /> SANITARY SEAL: <br /> Well is sealed between Pump and casing Yes [2 1 NoE NAE1 <br /> Seal between all pipe colulnins and casing Yes V I NoEl INAEJ <br /> iSOUnding lube/air vents sealed properly JYes [I No ❑ NA <br /> 'Chlorination poft available and sealed properly IYes Z INoMINA Fj <br /> SAMPLE TAP AND BACKFI-Olrif PREVENTION. <br /> Non-threaded sample tap betvveen well head and <br /> chieck valve or within 3** of well head IYesk I\IoF—IINA [:] <br /> !Adequately installed check valve or BFP device Yes )—✓ NoEIINAO <br /> No cross connections (ex: chemical feeders <br /> !hooked to distribution SYSLeeniiag flood irrigation <br /> i from domestic supply) Yes n No ❑ NA <br /> !Air gap of at least 61' (same as pipe diameter) I YesEl jNol:] INA [✓� I <br /> 1111AINTENANCE: <br /> Well/Pump visible and protected from damage Yes W No ❑ NA F] I+ <br /> Well/Pump free from excessive vegetation Yes [e No [:] NA El <br /> MISCELLANEOUS. <br /> Permit drawing represents actual location of well IYes [A,.l No El <br /> Per}nit drawing sufficient 'Lo locate well in future Yes to/ jl\lo ❑ If-no'is selected, a-Li2ch an accurate map toper Pit <br /> Photograph taken andattachedto record IYes L� INoEj <br /> -0 TH'I:-R: <br /> G o rn in e nts <br /> I! ►"s PpG `� (Z-1-( klz tt It, i tt Ue e( <br /> inspected 13 Title: <br /> - - H. <br /> Received By: Date: <br />