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5 PJ`E J 0 AQ U IIN! C 0 U N T Y <br /> DxiRONINIIENTAL HEALTH DEPARTMENT <br /> 'J868 -[Z@Sj HaZelton Avenue, Stockton, CA 95205-6239 <br /> T-cfqDhoaa:(209)468-3420 F'-ax: (209)468-3433 ILIVO.,vmv.sig.2�.or /ehd <br /> PUNIP NSPECTM CHECK LIST <br /> Address: ROo-6 Permit.. Inspe tion Date: <br /> Ilii \ P��-N�Qvz,SC . T�, �-� C .. - -1 o� <br /> t) <br /> CotiiriieiiisIR4easLi-emc-ii-ts-I <br /> Meets SJC StS-ndards? <br /> Rercm, mendatlo, ns <br /> C'E 111i E N P E D E S T A L.: <br /> Dimensions Of surface seal (2'x2'x4" minimum) Yes [I No ❑ I NJAEI I <br /> Casing extends at least 12" above grade Yes No ❑ NAE] <br /> Casing extends at least V 21DOVe pedestal Yes 1,,,[oE] NAE:1 <br /> Free of cracksfcon'Liguous with annular seal Yes No El NAO <br /> Graded to allow drainage away frorn casing Yes NoEl INAE] I <br /> SAIKIIITARY SEAL: <br /> Well is sealed be-Meen pump and casing Yes Kh 1e0 ❑ iNA El <br /> Seal bethAteen all pipe COIL111-HIS and casing Yes [A No ❑ I NAE1 <br /> Sounding tube/air vents sealed properly 1'J0 El INA El <br /> Chlorination poll available and sealed properly No NA <br /> SAMPLE TAP 1,11MID BALK17LOW PRIEVENTION: <br /> NIon-threaded sample tap between well head and <br /> check valve or within Tor'wellhead �Yes d— Ivo [] �NA [:] <br /> Adequately installed check valve orBFP device IYes [j NL, [:IINAE] I <br /> l,,Jo cross connections (ex: chemical feed=-I--q <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) YesEl NA NAE1 <br /> Air gap of at least 6-' (same as pipe diameter) No El INAEJ I <br /> MAI NTI N ANI C E: t <br /> ',,-Veil-/Pui-iip visible an-d. protected from darnage Yes ..NonINA-0 I. <br /> Well/Pump free from excessive vegetation Yes NoE:1 I NAE1 I <br /> I ELLANEO US.- <br /> Permit drawing represents actual location of vvell IYes JNoE1 <br /> Perniii dravOng SO icient to locate vvell in future IYes jNoE1 rno'is seiected,attach an accurate ma-vto permit <br /> 1 Photograph taken and attached to record I Yes INo ❑ <br /> iOTHER: <br /> Inspected By: Title: <br /> Received By- D at e: <br />