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N. COUNITY <br /> SA.N,JOAQWI <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fox: (209)468-3433 K/6b:wvvv,/.sjgov.orq/ehd <br /> PUNIP UkISPECTION GFIECK LIST <br /> 'Address: Inspe fion Dace <br /> 30 4:7.6 C - Peo H2 &C-Clop) Sf-00 -7 93 cl <br /> Pararneter/8"tandard Meets AJC Standards? Comrndn1S1hrjeaSL1rernents1 <br /> Recommendations <br /> ICEMIENITPEDESTAL. <br /> Dimensions of surface seal (2`x2'x4" n­ljnimum) Yes [� 1 Nob INA ❑ <br /> Casing extends at least 12" above grade Yes 1;? 1No [:1 INAD <br /> iCasing extends at least Vabove pedestal Yes Q No [:1 INA ❑ <br /> Free of cracks/contiguous with annular seal Yes IN o [:11 NA F1 <br /> I Graded to allow drainage away from casing Yes I No [:1 INA 0 1 <br /> SANITARY SEAL: <br /> iWell is sealed between pU11,11D and casing Yes No 0 NAD <br /> Seal between all pipe columns and casing IYesNo [:1 I NA, [:1 <br /> ;Sounding tube/air vents sealed properly IYes 0 NoOINAM <br /> Chlorination port avail-able and sealed properly I Yes R No 0 INA D <br /> ISAPOPLE TAP AND BACKFLOAAT PREVENTION. <br /> Non-threaded sample tap betvveen well head and <br /> cl-,eck valve or within 3' of well head Yes Fj_jl No E:l INA 0 <br /> Adequately installed check valve or BFP device Yes F% <br /> 1 2 No Ej INA El <br /> 'No cross connections (ex: chemical feeders <br /> !hooked to distribution system/ag flood irrigation <br /> ;from domestic supply) 1Yes Ej NoEl NA[j2 <br /> Air gap of at least 6�" (same as pipe diameter) IYes 0 1 No [I INA <br /> it MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V No E] INA El <br /> Well/Purnp free from excessive vegetation Yes 9 No 0 INA ❑ I <br /> MISCELLANEOUS,, <br /> ski <br /> Permit drawing represents actual location of well h1es No <br /> Permit drawing sufficient is selecte <br /> .ent to locate well in future 1Yes I No ❑ d, aftach an accurate map-LO Perm L <br /> !Photograph taken and attached to record (es <br /> 'OTHER: <br /> ins pected By: Tit-le: <br /> Received By: Date: rr <br />