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S <br /> SAM 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:www.sjgov.orglehd <br /> 0�` QA.- INSPECTION CHECK LIST <br /> Address: Permit,: Inspection Date: <br /> 4 k10k, c <br /> Parameter/Standard Meets SJC Standards? Corn entslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes j I No ❑ NA <br /> Casing extends at least 12" above grade Yes ❑ INoD NA <br /> Casing extends at least V above pedestal Yes ❑ I No ❑ NA <br /> Free of cracks/contiguous with annular seal Yes [� No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes RY No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA 9 <br /> Chlorination port available and sealed properly Yes [V 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 ❑ NA <br /> Adequately installed check valve or BFP device Yes ❑ No ❑ NA 9 <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [4 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Isd <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [4 JNoE1 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 IYes [� No ❑ <br /> OTHER: <br /> Comments: <br /> I <br /> Inspected By: Title: <br /> Received By: Date: <br />