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Jolmqauj,,� G On!"ry <br /> ENIVIRONIMBITAL HEALTH DEPARTMEi\j-r <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tehaphone: (209)468-3420 Fax: (209)468-3433 IvVeb:vArqxfv.sjqov.orgjehd <br /> P U,1111 P I�T`37 P E C;T11 0 ki C ECC L ST <br /> Address: Permitt.: Inspection Date: <br /> k, <br /> conarn r�11tM)APa'm C711fe-1 <br /> ParanieterlStandard NfieetS SJC SLandards? Rc-com, mendations <br /> C,ERTIENT PEDESTAL. <br /> Dimensions Of Surface seal (2;x2'x4" minimum) IYes A lNo ❑ INA [] 1 <br /> —4 <br /> Casing extends at least 12" above grade Yes 'L\j 1\1 0 [:1 INAE] I <br /> Casing extends at least 1" above pedestal Yes Ij No 0 1 NAE] I <br /> Free of cracks/contiguous with annular seal Yes NoEl I NAE1 <br /> Graded to allover drainage away from casing Yes I No [:1 INAE] I <br /> SANITARY-SEAL. <br /> Well is sealed between pump and casing Yes No [] NA <br /> Seal between all pipe columns and casing YesEl INo [A NAE1 I <br /> Sounding-tube/air vents sealed properly Yes Q INo D NA 1j I <br /> Chlorination port available @.nd sealed properly IYes 4 INoE:1 NA[I I <br /> SAMPLETAIP AND SACKFLOW PREVEI\JTION: <br /> Non-threaded sample tap between well head and <br /> I <br /> check valve or within 3' of well head Yes. o F_J NIA <br /> .Adequately installed check valve or BFP device YesEl No 111 NAEJ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> from om domestic supply) Yes El No NP, E] <br /> Air gap of at least 6" (same as pipe diameter) I YesEl INoEj INA j I <br /> M A I N T LE N A NC E: <br /> NA' <br /> ID JI '14 I <br /> Well/Pump visible and protected from damage Yes -No F� <br /> ,V\,1elJJPuml:)free,frorn excessive vegetation IYes No ❑ I NIA <br /> F,,ql§C ELLAMEM'O US: <br /> Permit drawing represents actual location of well IYes NoE] <br /> i Permit dravAng Sufficient to locate welt in future I Yes NoEl lf'no'is selected,attach 211accurate map to permit <br /> j Photograph taken and attached to record l'ifes N o El <br /> OT HI E R: <br /> Comments, <br /> 1% <br /> Inspected By: ITine: <br /> Received By: Date: <br />