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SJAN jOAQUIN COUNTY <br /> E1--dV1RO1',,11VjEN, TAL HEALTH DEPARTMENT <br /> 1868 East Flazelt-Oii Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 FaX: (209)468-341-33 Web:vArvw.sjqov.orq/ehd <br /> PUNIP WSPE CTUN CFECK UIST <br /> 11Address: <br /> Co LL I Ro GArur —permro: 0 3 (D <br /> tz <br /> Commeits/AreaSUre <br /> nents/araineter/Staidard Meets�, aldarcs? <br /> Recornmeiidatimis <br /> CEME1,Q]TPEDES TAL: <br /> Dimensions of surface seal (2"x2'x43' minimum) Yes R I-No [--] NIA 0 <br /> lCasing extends at least 12" above grade Yes LA No n INAE1 I <br /> I Casing extends at )east V above pedestal I Yes [tel INoE1 INA D I <br /> Free of cracks/contiguous with annular seal IYes NoE] 1",IAE] I <br /> Graded to allow drainage away from casing I Yes V NoEl INA D <br /> SANITARY SEAL: <br /> !Well is sealed between IDLIMID and casing Yes NoE:1 NA ❑ <br /> ISeal between all pipe columns and casing _Yes D No ❑ INA ❑ <br /> ;Sounding tube/air vents sealed properly Yes F-1 No [I NA Li? <br /> iChlorination port available and sealed properly Yes I No 0 NA [:1 <br /> SAMPLE TAP AND BACKFLOW PREVENTION- <br /> Non-threaded sample tap between well head and <br /> cl-,eGk valve or within 3' of well head I Yes No L7 INA [I <br /> Adequately installed check valve or BFP device I Yes No 0 NA Fj <br /> No cross connections (ex: chemicalfeeders <br /> !hooked to distribution system/ag flood irrigation <br /> I <br /> ;from domestic supply) Yes Ej NoEl NA U <br /> ;Air gap of at least 6" (same as pipe diameter) YesEl No 0 INA 2 <br /> 1110AINTENANCE: <br /> 'Well/Pump visible and protected from damage I Yes INoOINAO <br /> Well/Pump free from excessive vegetation I Ye NoEIINAr <br /> - I <br /> MISCELLANEOUS: <br /> -Permit drawing represents actual location of well Yes 2 N 0 <br /> Permit drawing sufficient to locate well in-futui-e Yes No L-1 lf'no'is selected, 2-ft2ch an accurate map-Lo permit <br /> Photograph taken and attached to record Yes INo El <br /> 10 T FIEF. <br /> Con-jiments, <br /> J- Cz 114 <br /> Rt�sP.ec <br /> k II <br /> --cl <br /> inspectedTitle: <br /> Ely; <br /> Received By: Date: <br /> r-u /.-rin <br />