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SAN jOAOU]f\]. (",01-INTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-30420 Fax: (209) 468-3433 V116b:vv\nAv.sjqov.arq/ehd <br /> P URAP I NISPECTION CH ECS UST <br /> Perini'�r mjH.a <br /> Inspe 'lop ate: <br /> I 7r p gate: <br /> Address.. -R&C464 CA7hpe oil/ <br /> 4 ih fQj <br /> Pararneter/Standardry � Meets AJC Standards? Comments[Me: <br /> ReGOMmendations <br /> GEMENTPEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes V INo IA F-1 I <br /> Casing extends at least 12" above grade Yes No M INAP <br /> Casing extends at least 1" above pedestal Yes No [] INA❑ <br /> Free of cracks/contiguous with annular seal IYes V NoE] NA E] II <br /> Graded to allow drainage away from casing Yes VI NoEl NAE] <br /> SANITARY SEAL: it <br /> Well is sealed between pump and casing Yes [2 No Fj NAE1 <br /> Seal between all pipe columns and casing Yes V No F-I NA D <br /> ;Sounding tube/air vents sealed properly Yes V I No El INA El <br /> lChlorination port available and sealed properly Yes I No L1 INA F-1 �j <br /> ISAMPLE TAP ANID BAGKFLMrV PREVENTION: <br /> Non-threaded sample tap between well head and <br /> chieck valve or within 3' of well head Yes V No 0 NAD <br /> Adequately installed check valve or BFP device S <br /> l I ,VeIV No F❑I NA El <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> ifi-orn dornestic supply) Yes [:1 No 0 NA <br /> !Air gap of at least 6" (same as pipe diameter) IYes.E1 INo D NA <br /> 1MAINITENANCE: <br /> Ii <br /> Well/Pump visible and protected from damage IYes 9 No El INA El II <br /> Well/Pump freefromexcessive vegetation IYes � No 0 1 NAE1 I <br /> MISCELLANEOUS, <br /> Pen-nit drawing represents actual location of well Yes IN o ❑ <br /> 'Permit drawing sufficient to locate well in future Yes I No <br /> El ll'no'is selected,attach an accurate map to permit <br /> 1,Photograph taken and attached to record Yes No ❑ <br /> 11,0THER: <br /> G-o m rn e n is: <br /> 1. <br /> linspected By: <br /> ITile: <br /> Received By: <br /> D at C-: <br /> 1--U A^rin <br />