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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East H2.7elton Avenue, Stockton, CA 95205-6232 <br /> 7"efesphorie: (209)468-3420 Fax: (209)468-3433 Web:vvyM.sj.qov.orgLehd <br /> +-,i�[INSPECTION CHECK UST <br /> Addr6ss: Permit#.: Inspection Date: <br /> \k)�rj 0 3� <br /> Qn <br /> ments/ <br /> Parameter/standard Meets SJC Standards? C 0 11-t rl <br /> Recommendations <br /> k-'EMENT PEDESTAL: <br /> Dimensions Of Surface seal (2'x2'x4" minii-num) Yes 11 No 1:1 NA El <br /> Casing extends at least 12" above grade Yes El No El NA El <br /> Casing extends at least V above pedestal Yes El No [I NA El <br /> Free of cracks/contiguous with annular seal Yes F-1 No [:1 NA F1 <br /> Graded to allow drainage away from casing Yes 0 No ❑ INA El I <br /> SANITARY SEAL: <br /> Well is sealed between PLIMP and casing Yes El I No [:1 INA F] I <br /> Seal between all pipe columns and casing Yes D No D INA E:l I <br /> Sounding'LLIbelair vents sealed properly Yes E] No El INA El I <br /> Chlorination poll available and sealed properly Yes F] No E] INA 0 1 <br /> SAFOPLETAP AND BACKFLOW PREVENTION. <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes Fj No F] <br /> j NIA ❑ <br /> Adequately installed check valve or BFP device No El NA El <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systlem/ag flood irrigation NA <br /> I <br /> from domestic Supply) Yes 0 No ❑ <br /> .Air gap of at least 65' (same as pipe diameter) IYes El No El NA ❑ l <br /> MAIKITLI-NANCE: <br /> visible and protected from damage Yes E] No F-1 NAEl <br /> ;Well/Pump free,from excessive vegetation Yes El No 0 NA El <br /> IOUSCELLANEOUS: <br /> Permit drawing represents actual location of well Yes El No [] <br /> Permit drawing sufficient'Lo locate well in future Yes El No El rno'is selected.attach an accurate map to permit <br /> Photograph taken and attached to record Yes D INo El <br /> I CST[EER: <br /> 0 111111 e lnf.s: <br /> Inspected By. iTitle: <br /> Received By: Date: <br />