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' SMNjOAQD|0G"DUNTY <br /> . . <br /> ENVRONMENTALHEALTH DEPARTMENT <br /> 18O8East Haze8onAvenue, Stockton, CAA52OS'6232 <br /> 7�/�o�une�(2O8\488-3420��x� (209)468-3433 k�6b: <br /> ' `� ' ` ' <br /> Ll SLI1 <br /> SPECT110NI CHEM', <br /> PUMP W <br /> Casing extends at least 12" above grade YesF-1 Nl o E:1 NAE] <br /> Casing eXtends at least 1" above pedestal Yes 0 1\1 oF]_ NA[I <br /> Graded to allow drainage away from casing Yes 0 No n NAE] <br /> Well is sealed between PLImp and casing I YesF1 No EIINAD I <br /> Seal between all pipe columns and C2Sil1g I YesEl No [:] NAE] <br /> Chlorination poll available 2nd sealed properly I Yes E] NoE] NAD <br /> ,SAMPLE TAP AND BACKFLOVIV PREVENTION: <br /> lNon-threaded sampletap between well head and <br /> check valve or within T of well head 1YesE1 No Ej NAE1 <br /> —tely fristalled check valve or BFP device �YesF—] No [:] NAE1 <br /> No cross; connections (ex: chemical feeders <br /> Ihooked to distribution system/ag flood irrigation <br /> fi-on-i domestic supply) Yes El NoF-1 NAE] <br /> ;Air gap of at least 6" (same as pipe diameter) I YesEl No 0 INAE] I <br /> NA <br /> Well/Pump visible and protected from darnage YesE] �No <br /> Permit drawing represents actual location of well Yes F-1 NoEl <br /> Permit drawing SUfficient to locate well in future NoEl lf'no'is selected.2U26 21)2CCUrate map to permit <br /> Photograph taken and attached to record JYes 0 1 NoEl <br /> Inspected By: PTI I <br /> Received By: Date: <br /> .,..... <br />