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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 efepfrone;(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> INSPECTION CHECK LIST <br /> Address: � Permits: Inspection Date: <br /> ParameterlSfandard Meets SJC Standards? Coin mentslMeasulernentsf <br /> ReCoinmenda ions <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes SA jNoE1 NA❑ <br /> Casing extends at least 1" 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 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns aiid casing Yes No ❑ NA❑ <br /> Sounding tub air vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes &t No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within T 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 /> frorn dornestic supply) Yes ❑ No d 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 frorn excessive vegetation Yes 4 JNo ❑ NA❑ <br /> MISCELLANEOUS. <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes E iNo ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> pr cx� <br /> Inspecfiedlay: Title: <br /> Received By: Date: <br /> - n/n.l lnnA C <br />