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t <br /> SAKI JOAQUli4 COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefep/roue:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/eild <br /> _ PUE1,iIP INSPECTION CHECK LIST <br /> P:ddress: ^T Permit#.- inspe tion Date: <br /> u", p`yXb3�O s <br /> Pararneter/Standard Meets AJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 41 No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes & No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes 11 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes IND ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination poll available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE 'f Air AND BACKI=LOCA PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of wellhead Yes No ❑ NA ❑ <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 domestic supply) Yes ❑ No NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAM I <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Na ❑ NA❑ <br /> MISCELLANEOUS: I <br /> Permit drawing represents actual location of well Yes No ❑ <br /> !Permit drawing sufficient < <br /> xo locate well in future No ❑ <br /> if'no'is selected,attach an accurate map to permit <br /> Yes <br /> Photograph taken and attached to record Yes No ❑ <br /> OTTER: _ <br /> Comments: <br /> i <br /> I <br /> Inspected By: Title:_ , <br /> Received By: Date: <br />