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Ujj,� G.'OUNT", <br /> ENVIR'ONIMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tbfe-,jj-ho!?9: (209)468-3420 F-*ax: (209)468-34330 IfiVeb:yirww.Sjqov,or_q/e11d <br /> PUNTIP WSPECTION CHECI,,\" LIST <br /> n— Date: <br /> Address: Permit"".. 100 <br /> Inspection <br /> 7->(Z6 W9 b(3 <br /> Pararne-'Ler]-Stanclard Meets SJC Standards? <br /> Recommendations <br /> —CE,111—EW—TP—ED E S—TA LT <br /> Dimensions Of surface seal (2'x2'x.4" minimum)_Yes No 0 NAE1 <br /> Casingextendsat least 12" above grade Yes NoFj NAE1 <br /> I Casing extends at least 1" above pedestal Yes No ❑ INAD I <br /> Free of cracks/contiguous with a1111Ul@r Seal Yes J No F] I 1141AE] I <br /> Graded to allow drainage away from casing Tiles4 No [:] INAE] I <br /> SANITARY SEAL: <br /> Well is sealed between JR1111P and casing Yes [j INo [:11 NAE1 <br /> Sea] between all pipe columns and casing Yes [j NoO INA[:] <br /> Sounding lube/air vents sealed properly Yes ❑ No 0 NA J <br /> Chlorination poil available and sealed properly iYes JNoE1 NAE] I <br /> -SAFITIPLE TAP AND SACKFLOW PREVE[,,R'l01,'%J: <br /> Non-threaded sample tapbetweenwell head and <br /> check valve or within 3' of well head — - I'Yes NoE] I NIAE] <br /> Adequately installed check,valve or CFP device jYes W No [] I NAEj I <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systleni/ag flood irrigation <br /> from domestic SUPI)ly) Yes 0 Noll NA E] <br /> ,Air cap of at least 6" (same as pipediameter) IYes-E1 INo El INA [j I <br /> MAINTLE NANIC E-. <br /> 'Well/Pump visible and protected from damage YesNon NAE1 <br /> 'Well/Pump free from eX,cessive vegetation s No [:1 NA El <br /> DO['§C E L L A N E 0 U-S <br /> Permit drawing represents actual location of well Yes No ❑ <br /> , <br /> Permit drawing sufficient to locate well in future Yes NEl ii'no' scleeted,attach all aCC.Urate map t..-j permit <br /> o <br /> i Photograph taken and attached to record Yes alNo El I <br /> 10THER: <br /> \AN <br /> 7�WInspectec By: ITitin: <br /> Received By: Date: <br />