Laserfiche WebLink
' SAN JOAQUIN'COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefephrone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.or /c�ehd <br /> PHWMNSPECTI®N CHECK Ll T <br /> Address: Permit#: Inspection Date: <br /> o 1� <br /> Parameter/Standard Meetsts SJC Standards? Coin ments/Measurem entsfRecommendations <br /> CEMENT PEDESTAL.: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA <br /> Casing extends at least V above pedestal Yes ❑ No ❑ NA 1j <br /> Free of cracks/contiguous with annular seal Yes Ey No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Ye No NA❑ <br /> Seal between all pipe columns and casing Yes Q No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA 9i <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA <br /> SAMPLE TAIL AND BACKFLOIS! PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ No ❑ NA r� <br /> Adequately installed check valve or BFP device Yes ❑ No ❑ NA <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> frorn domestic supply) Yes ❑ No ❑ NA 19/ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[j <br /> MAINTENANCE: <br /> VVell/Pump visible and protected from damage Yes .No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Qj I No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes Lj 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: � �v�� Title: <br /> Received By: Date: <br /> .. 1 fl fh A InAA C <br />