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SAN JOAQUIN COUNTY <br /> Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:wwvd.slgov.orq/ehd <br /> _ PUIVI-P '''�..SPECT ION CHECK LIST <br /> Address:_ P f : <br /> ( J I VG�IV SKO0 li� Pion ate: <br /> Parameter/Standard Mees SJC Standards? CornmeliTsffileaSUrementsf <br /> Recommendations <br /> CEIVIENT PEDESTAL: -- - <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ I NA❑ <br /> Casing extends at least 12" above grade Yes 2 No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal _YesV No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes S�j No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes V1 No ❑ INA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 52 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes W No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ <br /> 1SAMPLE TAP AND BACKFLOW PREVENTION: � <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head 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 ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from darnage Yes &Z No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [Z No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes U No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ l 'no'is selected,a<iach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> 00 s a,m p11 .gyp 1";1-S <br /> i <br /> Inspected By: Q Title: - (4• <br /> Received By: Date: <br /> cu ngnn <br /> S2/2 d/7 n•I r <br />