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Slvi Joll,nauml(-,oljl�rry <br /> Ei\.,v1R'ONJK/jEN1TPIL HEALTH DEPARTMENT <br /> '1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefcaphona:(209) 468-3420 Fay: (209)468-34303 Ifiveb:xhAWd.sjqov.oLg/ej1d <br /> P U M1 P IncS P E 0 T 110 N C FIE C f,C L I SIT <br /> Addr6ss: Pe": Inspection Date: <br /> bc>315A kAib ...Tt <br /> Parameted-Standard Meets SJC Standards? Cai-i�nentS/Measuremen <br /> Recommendations <br /> Dimensions Of Surface seal (2'x2'x4" minimum) IYes INIoEl INAE] I <br /> Casing extends at least 12;' above grade IYes No Fj INA El I <br /> Casing extends at least V above pedestal I Yes F4 I No F-1 NA F1 I <br /> Free of UaCkSkollflgUOUS with annular seal Yes No [] NA <br /> Graded to allow drainage 2-way from casingE1 <br /> 011 NA <br /> SANFFAR�(SEAL: <br /> Well is sealed between purnp and casing Yes [O INoE1INAO I <br /> Seal between all pipe columns and casing Yes U NoEl INA I <br /> F - � <br /> Sounding tube/airE]be/air vents sealed properly Yes No 0 NA I <br /> Chlorination poiZ available and sealed properly I Yes [:] NoEl INA[j I <br /> SAFOPLE TAP AND BACIr,"FL01"d PREVENTION: <br /> Non-threaded sample tap between we*11 head and <br /> check valve or within 3' of well head Yes El No El �NA rJ <br /> !Adequately installed check valve or CFP device I YesEl No [:] INA V\-S� <br /> No cross connections (ex: chemical feeders <br /> 1hooked to distribution system/ag flood irrigation <br /> Tron-i domestic supply) I es El No [j NA El <br /> Air cap of at least F (same as pipe diameter) IYes No 0 INAE] liI <br /> MAINTENANCE: <br /> ik/Vell/Pump visible and protected from darnage Yes No ❑ NA❑ <br /> !Well/Pump free frorn excessive vegetation Yes No E NAEJ <br /> M lk E LLAN EO U,8 <br /> :Permit drawing represents actual location of well 1Yes j NoEl <br /> 0 11'no:is selected,attach an accurate map tc)permit <br /> 1 Permit drawing sufficient to locate vvell in futuire es No <br /> Yes <br /> Photograph taken and attached to record 'A <br /> jY e INoE] <br /> OTHtER: <br /> Coninients: <br /> Inspected By: ITitle: <br /> Received By: Date: <br />