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e <br /> SI,`i•:f rC1�',�uIF. E:olJi\'1'l <br /> ENViP,01'IMENTAL HEALTH DEPARTMIE%rr <br /> 1360 East}la%elton Avenue Stockton, CA X5205-6232 <br /> Tefep hmae:(209)468-3420 /-'ax: (209)468-3433 vvvr,,v.slgov,org/ehd <br /> PUiVlf,a; MISP1::;CT1�.:�N1 CIIHECiI, U1'1`31 <br /> IjFrMA5 �D�S�u� Y`�Q WQIV V �,OInspeh <br /> a Date: <br /> r i r d Meets SJC lot2nda.rds? CollErlenis/1�Ieas!ienle!lw/ <br /> Pa I'c.11l B ie I'��''L ll G n: -- <br /> _ iiECOliir,leild2t!OilS <br /> C E 1't!i E—NT i"—F-.D <br /> l~S FF ---—� �� _�_ -- – ---- —,�• �.- ----- - <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ INAD <br /> Casing extends at least 12" above grade Yes No ❑ IIIA ❑ <br /> Casing extends at leasi V above pedestal !Yes No ❑ NP,❑ <br /> Free of crackslcontiguous with annular seal Yes No ❑ l IA❑ I ! <br /> Graded to allovt/ cirainage away from casing 'es 1\10 ❑ Nr; ❑ <br /> r� i <br /> SANITARY SEAL. i <br /> I <br /> Well is sealed between purnp and casing Yes No ❑ INA❑ I ? <br /> Seal between all pipe columns and casing jYes No ❑ NA ❑ I <br /> I Sounding tube/air vents sealed properly - 41'esNo ❑ NA LIChlorination port available and sealed properly No [:1INA❑ <br /> �SANIPLC T1111" ANID SPCCtR.CV'J PRC:.V1;NTlOtt: j <br /> Non--threaded sample tap i-etween vvell head and <br /> check valve or within 3' of well head Yes [� No ❑ NA ❑ <br /> Adequately installed check valve or PFP device Yes (� No ❑ 1 NA ❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to dlstrlbUtlGn system/ag flood irrigation <br /> Trom domestic supply) Yes ❑ No [j NAEJ <br /> Air cap of at least o' (same as pipe diameter) OEI NA <br /> MAI NTE NANC,I' <br /> kNell/Pump visible and protecied from darnage 4,eN <br /> No ❑ [��A ❑ <br /> Well/Pump free from e-):cessive vegetation o ❑ NA ❑ <br /> I <br /> Permit drawing represents actual location of tve!I Yes No ❑ <br /> Permit drawing sufficie?lt to locate well in future Yes No ❑ I li'no`is selected,a--'tach an accurate m.ap to permit <br /> l <br /> , <br /> !Photograph taken and attached to record Yes ��o ❑ <br /> OTHER: I <br /> Goniments: <br /> f <br /> i` <br /> II <br /> n Y <br /> fl _ <br /> jir!s,)ccted D—y: Title: I, <br /> Received Sy: Date: C <br />