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• SAN JOAQUIN. (,,0UNTY <br /> ENIVIRONIMEN. TAL HEALTH DEPARTMENT <br /> 1868 East Ha7e]-*-LO n Avenue, Stockton CA 95205-6232 <br /> Lo <br /> Telephone: (209)468-3420 Fox: (209)468-3433 14,16b:VAfAfv.sjq0v.0rq1ehd <br /> PUVV-IP VNNSPECTIDN CHECK LIS-F <br /> Address: <br /> V-_;.., Inspiction pate: <br /> 616 S H4it L A-4 pn--�+ 0— 66 9 111 if /I I <br /> it Parameter/Standard Meets SJC Standards? COMM 8r1fS1Ar)eaSL1rernents1 <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 2 Noo NAD <br /> Casing extends at least 12" above grade Yes W No R NA El <br /> !Casing extends at least V above pedestal Yes El No R1 NA F1 <br /> � 6 <br /> Free of cracks/contiguous with annular seal Yes No 0 NA❑ <br /> Graded to allow drainage away from casing Yes L? NoEl NA 0 <br /> SANITARY SEAL: <br /> Well is sealed between PUMID and casing Yes [Z No 0 INA ❑ <br /> Seal between all pipe columns and casing Yes 5� No El INA D <br /> ;Sounding tube/air vents sealed properly Yes No 0 INA E] <br /> Chlorination port available and sealed properly Yes [j/ NoE] INA [:1 <br /> SA1111PLE TAP AND BACK]FLOYti PREVENTION: <br /> Non-threaded sample tap between well head and I NAE] <br /> check valve or within 3' of well head Yes P No I <br /> Adequately installed check valve or FFP device Yes No El NA El <br /> No cross connections (ex-. chemical feeders Ij <br /> (hooked to distribution system/ag flood irrigation <br /> ;from domestic supply) Yes E] No 0 NA <br /> gap I at least 6"' (same as pipe diameter) Yes 0 NoEl NA J I <br /> of <br /> ,NIAINITENANGE: I2 <br /> !WelliPurnp visible and protected from damage Yes No Ej NA 0 <br /> I - F <br /> IVVell/Pump free,from excessive vegetation IYes2r NoDINAF] <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes U NoEl II <br /> rPermit drawing sufficient to locate well in future Yes W No If no'is selected,a-Liach an accurate map-Lo permit <br /> 111Photograph taken and attached to record Yes No F1 <br /> OTHER: A i <br /> Comments.- <br /> SevrwP /1%,3 eq, <br /> CCU � � . <br /> inspected By: VOL'U Ag <br /> Received By: Dare: <br /> r�j-[ <br />