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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www,sjgov.org/ehd <br /> PUNIP INSPECTION CHECK LIST <br /> Address: Permits: T <br /> ecfion Date: <br /> Parameter/Standard Meets SJC Standards? comments! easurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: ~� <br /> Dimensions of surface seal (2'x W" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ j <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 Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes ,C7 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ —1 <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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [�41 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes [ No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage 4Ye <br /> No ❑ NA El <br /> Well/Pump free from excessive vegetation No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in futureYes No Ellf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No El <br /> OTHER: _ <br /> Comments: <br /> Inspected By: �A pDa <br /> 55\ <br /> Received By: <br />