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SAN JOAQUIN COUNT`( <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> PUIVIP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> L444. t��0 p�v� Q o bu3 1 <br /> ParameterlStandard Meefs SJC standards? CommentslMeasuremenfs/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes F4 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes q No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes Fj No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing 1'es 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 01 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 T of wellhead Yes F� No ElNA El <br /> Adequately installed check valve or BFP device Yes [I No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dornestic supply) Yes ❑ No [� NA❑ <br /> Air gap of at least 6' (same as pipe diameter) Yes ❑ No ❑ NA[4 <br /> MAINTENANCE: <br /> Well/Pump visible and protected frorn damage Yes No ❑ NA❑ <br /> Well/Pump free frorn excessive vegetation Yes No ❑ NA <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit 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 /> Comments: <br /> Inspected By: Title: Y/,"\ <br /> Received By: Date: <br />