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SAN JOAQUIN'COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> INSPECTION CHECK LISA <br /> Address: rPermit#.:^ O � Inspection Date: <br /> Parameter/Sfandard Meets AJC Standards? Comments/Measurements/ <br /> Recomrnendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes j No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes Q( INoE1 NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Ej 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 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ No INA ❑ <br /> Adequately installed check valve or BFP device Yes 9 No ❑ NA❑ QOWQS\-�- vL. WjV <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 ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes SP INoE1 INA <br /> MI§CELLANEOUS: <br /> Permit drawing represents actual location of well Yes INoE1 <br /> IPermit drawing sufficient to locate well In future Yes No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Con-irne>nts: <br /> I <br /> Inspected By: VWN Title: <br /> Received By: Date: <br /> nlnA llltAC <br />