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SAN dOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stocl<ton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web www.slgov.orq/ehd <br /> PUIVIP INSPECTION CHECK DIST <br /> Address: Permit#: Inspection Date: <br /> � 0'13 0S to <br /> ParameterlStandard Meets SJG Standards? Coin mentslMeasuremen'tsI <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes 0 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [4 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 U No ❑ NA <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Ij <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA[i <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 ❑ lNo ❑ NA i <br /> Adequately installed check valve or BFP device Yes ❑ INo ❑ NA[j <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> frorn domestic supply) Yes ❑ No NA El <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: II <br /> 1/Veil/Pump,visible and protected from damage Yes No ❑ NA❑ <br /> VVel Pump free from excessive vegetation Yes No ❑ NA❑ j <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ 11'no'is selected,aiach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected Sy: YE— Title: <br /> Received By: Date: <br /> A(AA II AAC <br />