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DwIRONIMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefe-phoaa:(209) 468-30420 Fax: (2Q9)468-3433 lbleb:vA'vw.siqov.org/ehd <br /> PUNAP iNISIPECT11ON CHECK LIST <br /> Addr6ss: Permit#.: Inspection Date: j <br /> C C)n-,rn <br /> Parol m ete i-IS-la n cla r d Nrieets SJC Sta.ridards? Recommendations <br /> CEMENT PEDESTAL.: <br /> Dimensions Of surface seal (2'x2'x4" minimum) Yes I No El INA El I <br /> i Casing extends at least '12" above grade Yes I No ❑ INA [:1 1 <br /> Casing extends at least V above pedestal Yes Lu INc) [I INA El I <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA El I <br /> Graded to allow drainage away from casing Yes NoE1]NAE1 <br /> S A N!I TA RY SEAL: <br /> �_Vv—ell is sealed between pump and casing I Yes –Ldj INo Ll INAF-1 I <br /> Seal between all pipe columns and casing Yes j NoOINAE1 I <br /> 'Sounding tube/air vents sealed properly - Yes <br /> No ❑ INA ❑ <br /> port -4 <br /> Chlorination port available and sealed properly Yes No [:11 NAE1 <br /> ISAMPLETAP AP 4F) BACKIFLOIN! PREVENT IOIN: <br /> i <br /> Non-threaded sample tap between well head and <br /> check valve or within T of well head Yes j No ❑ NA 0 <br /> Adequately installed check valve or CFP device IYes 4 No El I NAE1 <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> TrOm dornestic SUJ:)jDJy) YesEl No NA El <br /> Air gap of at least 6;' (same as pipe diameter) I YesEl No 0 INA El I <br /> MAINTENANCE,, <br /> ;Well/Pump visible and protected from carnage Yes No ❑ <br /> NAE1 <br /> 7VVell/Pump free from excessive vegetation Yes No ❑ I\JA El <br /> :MISCELLANEOUS: <br /> iPermit drawing represents 2..CtL!21 location of well Yes Ij No El <br /> I <br /> Permit drawing sufficient to locate well in future Yes NoEl 1I"RO is Selected;attach an accurate map to permit <br /> I <br /> Photograph taken arid attached to record IYes I No ❑ <br /> iOTIAER: <br /> comnlents: <br /> Inspected By: Title: <br /> Received By: Date: <br />