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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 /> c �_S F �"?� INS ECTION CFIECK LIST <br /> Address: Permit-4: Inspection Date: <br /> Parameter/Standard Meets SJC Standards? (join mentslMeasurementsl <br /> Recominendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes J No ❑ INA Ej <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA <br /> Casing extends at least V above pedestal Yes ❑ No ❑ NA <br /> Free of cracks/configuous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA <br /> SANITARY SEAL: <br /> Well is sealed Yes No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA[4 <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ ANAChlorination port available and sealed properly Yes E] No ❑ <br /> SAMPLE TAF'AND 13ACKIFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes E] No ❑ NA[V] <br /> Adequately installed check valve or BFP device Yes ❑ No ❑ NA <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dornestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ INo ❑ 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 41 No ❑ <br /> Permit drawing sufficient to locate well in future Yes No F111 'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: I <br /> Inspected By: Title: <br /> Received By: Date: <br /> .. nf1.1(ITAC <br />