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JOAQUH C OUNTY <br /> B,,mFm,,(-)1-,,1MEHTAL HEALTH DEPARTMIENT <br /> 1868 East l-127elton Avenue, Stockton, CA 95206-6239 <br /> . L <br /> Tete-pftoae: (209)468-3420 [,*-ax: (209)468-343' MAGI)., vmvv.siqov.oj el-d <br /> PUM11' NSPECTION1 CHIEUK <br /> Permii�': Inspection Date; <br /> a—blbz" � uO lo-kfvL <br /> vy v��Q*I-j cpr <br /> Il Connm e ntsffirteas uvem en'S <br /> ParanneLeriSlandard Kheeis -JC,Standards? Recommen dat'.'oils <br /> ICEMENIT PEDESTAL.- <br /> Dimensions Of surface seal (2'x2'x4" minimum) I Yes NOF-1 INAE] IIi <br /> Casingextendsat least 12" above grade Yes L-j I N1 o 0 INAE] I <br /> Casing extends at least V above pedestal Yes 4 No [:1 NA El <br /> Free of cracks/contiguous with a.1111IL112r seal Yes a NoEl NIA 0 <br /> Graded to allow drainage away from casingFN <br /> Yes [U] No AD <br /> SAN HI-AFff SEAL: <br /> Well is sealed between pump and casing I Yes j No INAE] I <br /> Seal between all pipe columns and casing I Yes N o INA I <br /> SOL111dj11g tube/air vents sealed properly I YesEl No [:1 INA [j <br /> Chlorination poll available and sealed properly Yes [V NoEl I NIA[I <br /> SAMPLE TFAP AND BACKFLOVif PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within T of well head IYes El I No El INA [j <br /> Adeq u..ate ly installed check v-a lve or B FP d av-ice jYesE1 No I NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> Tlon-i domesticSUPIDly) Yes No ❑ NA <br /> Air gap of at least 6" (Sal-ile as IDilDe diameter) Yes ❑ No <br /> M A I KI TE N A N C E- <br /> V.Veil./Pun,ip visible an-d. protected from damage Yes ..No n IMA ❑ <br /> Mel!JPUrnp free from elxcessive vegetation Yes 91 No D l\JA El <br /> Fvt1 CELLANIEHOUS: <br /> Permit drawing represents actual location of vvell Yes k No 0 1 <br /> Pen-nit drawing sufficient to locate well in fuiure Yes No El if'nc'is ser ectEd,attach 21-1 accurate map to permii <br /> I/e N <br /> Photograph taken and attached to record IYes I t"J <br /> silt) F-1 <br /> i OT Hl E R: <br /> Qvj <br /> LN <br /> Title:inspectedBy: <br /> Received By: Date: <br />