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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazel' n Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax;(209)468-3433 Web:www.sjgov.org/ehd <br /> PUIVIP INSPECTION CHECK LIST <br /> Address: Perml0t.; Inspection Date: <br /> ( 0,<,L,---,Z P 00&ck23 \ 0 5 Iv o -Wo <br /> ParameterlSfandard Meats SJG Standards? CommentsImeasurementsl <br /> {recommendations <br /> CEMENT PEDESTAL= <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes • I No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes q No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes F3 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes INo INA ❑ <br /> Seal between all pipe columns and casing Yes [21 No ❑ INA❑ <br /> Sounding tube/air vents sealed properly - Yes ® No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes [ No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within 3' of well head Yes 41 No ❑ NAE] i <br /> Adequately installed check valve or 13FP device Yes No ❑ NA❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> from domestic supply) Yes ❑ No [d NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ INoE1 NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> 'Permit drawing sufficient to locate well in futureYes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments" <br /> t <br /> i <br /> Inspected By: Title: 5` <br /> Received By: Date: <br /> !tln.1 InnA G <br />