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SAN jOAQU1h1. C'.',OUi',,ITY <br /> ENIVIRONIME11TAL HEALTH DEPARTMENT <br /> `1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-30420 Fax: (209)468-3433 1,41ab:wv.,,vv.sip,ov.orq/e hd <br /> PUMIP INSPECTION CF-11JECK UST <br /> 33 <br /> I ddress: MAC k V,-UC- QJ-) ACA" Po P eWV00 T m 1*t-.,A, i9tion D 'e: <br /> q I lu <br /> PararneterlStandard y Meats SJC S'Landards? Comm en-ts[MeaSUrernentsi <br /> Reconunendations <br /> iCEFITIEKITPEDESTAL: <br /> IDimensions of surface seal (2'x2'x4".minimum) Yes ® No M IIJA 1:1 <br /> I —I. <br /> lCasing extends at least 12" above grade Yes V No F1 NAF-1 <br /> Casing extends at least V above pedestal Yes �D V NA [I lei) 41.,.. 1 <br /> Free of'cracks/configuouswith annular seal Yes [2 No El NAD II <br /> Graded to allow drainage away from casing IYes [Z I No 1-1 .1 NAEFJ1 I <br /> ISANITARY SEAL: <br /> Well is sealed between pump and casing Yes NoUNAE] I <br /> 'Seal between all pipe columns and casing Yes &r No D INA 0 <br /> ;Sounding tube/air vents sealed properly Yes E No ❑ NA <br /> Chlorination port available and sealed properly Yes Kt JNo 0 INA ❑ <br /> SAMPLE TAP AND BACKE-01TV PREVENITION. <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes W/1 �No <br /> Adequately installed check valve or BFP device IYes INo [—I NA <br /> 1 No cross connections (ex.- chemical feeders <br /> 1hooked to distribution systemlag flood irrigation <br /> iron domestic supply) Yes F I NoE] NA 5 <br /> lAir gap of at least 6" (same as pipe diameter) IYesE1 NoD ,NAR I <br /> IMAINITENANCE: <br /> Well/Pump visible and protected from damage IYes 2 INoE1 INAE:1 I <br /> it - P <br /> Well/Pump free fromexcessivevegetation .Yes 0 1 N oE] INA El I <br /> IMISCELLANEOUS' <br /> Permit drawing represents actual location of well —Yes -No <br /> Permit drawing sufficientL to locate well in future 7es INoE1 1-1'no'is selected, auft'2ch an accurate map to permit <br /> (Photograph taken and attached to record Ives 4NoE] <br /> JOTHER. <br /> — <br /> 1 Cor nients., <br /> Inspected By: (Title: 14- <br /> I'Received By: Date: <br /> r-u A-win <br />