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Ch!vIROPiNiEi l T P,L HEA T 1-I DEPPATIUIEIVT <br /> 1868 East I-la%elton Avenue; Stockton, CA 95205-6232 <br /> Teciepliciae:(209) 468-3420 :::ax. (209)468-3433 IV,46,5:vsn1vvv.sj.gov.org/eiid <br /> Address: � Permri#-: Inspection Date: <br /> LeL'k- , <br /> Parameter]Standard Nrieets SJC SLai dards? <br /> I Coi7Enn.ent-sllreasurem cnLc-/ ` T <br /> Recommendations �— <br /> -'r E'1'L'i P:NT PED-E.S TA L.: <br /> Dimensions of surface seal (2'x2'x4" minii-num) Yes I No ❑ INA❑ Ij <br /> Casing extends at least 12" above grade Yes No ❑ 1 NA❑ I <br /> I <br /> Casing extends at least 1" above pedestal Yes No ❑ INA❑ I ! <br /> Free of cracks/contiguous with annular seal Yes No ❑ INA❑ <br /> Graded to allow drainage- away from casing Yes hlo ❑ INA❑ <br /> SAiNTFARY SEAL: <br /> I <br /> Well is sealed between pump and casing Yes Ej No ❑ INA❑ 1E <br /> Seal between all pipe columns and, casing Yes j No ❑ NA❑ <br /> I Sounding tube/air vents sealed properly - IYes No7[:1NA Ef I I' <br /> Chlorination port available and sealed properly Yes 11No ❑ I NA <br /> SAMPLE TAMP Ak D SA N]"L.OW PRE Eifi[l€FJ: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head YesD No ❑ NA J <br /> Adequately installed check valve or SFP device Yes No ❑ I NA ❑ <br /> klo cross connections (ex: chemical feeders l <br /> hooked to distribution systemlag flood irrigation <br /> from domestic supply) 1'es ❑ No J NA ❑ <br /> .Air aap Of at least 6" (sarne as pipe diameter) Yes ❑ INo ❑ NA <br /> . I <br /> 10AII TLENANC E j <br /> !knell/Pump visible and protected from darnage iYes No ❑ f�iA ❑ <br /> Well/Pump free frorn excessive vegetation Yes No ❑ NA ❑ <br /> Ii11ISCELLAN''0U,S. <br /> ,Permit dravving represents actual location of well Yes No ❑ <br /> 1 Permit drawing sufficient to locate vvell in future Yes j�o ❑ If'ric'is sefec ed;arach an accur2 a^:ap to permit <br /> I <br /> I <br /> Photograph taken and attached to record Yes No ❑ <br /> i O TI ER: 1 <br /> li <br /> Inspected By: Vw�wTitle: � S <br /> }Received By: Date: <br />