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OH- <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Tefephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />-ROMP INSPECTION CHECK LIST <br />Add iress: <br />eV`k Q -T-A\C_ t_ CON Ar- • Crk \i...). h AS2-6 <br />Permit#: <br />trpcZ 0 0-2s—C -Z, \ <br />Inspection Date: <br />0 5/Dbi (6\_ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes pi No E [NA E <br />Casing extends at least 12" above grade Yes No I I NA E . - <br />Casing extends at least 1" above pedestal Yes R.) No n NA E I . • Free of cracks/contiguous with annular seal Yes Ei No n NA ii <br />Graded to allow drainage away from casing . Yes 11 No 1 NA n 1,./ GI- kis:u=1 /4-zi,-R I 5V Prk, <br />'SANITARY SEAL: 4-*c..c (c.,Sk tl--i Q4 t.v._. <br />Well is sealed 13EstaReeka.latottkiticelasing- Yes lj No I I NA n <br />Seal between all pipe columns and casing Yes n No 11 NA El <br />Sounding tube/air vents Sealed properly - Yes No n NA El <br />Chlorination port available and sealed properly Yes No n NA Ri <br />SAMPLE TAP AND BACKFLOW PREVENTION <br />Non-threaded sample tap between well head and <br />check valve or within 3 of well head Yes L No fl NA q <br />Adequately installed check valve or BFP device Yes E No I NA rj <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes No , si NA ri <br />Air gap of at least 6" (same as pipe diameter) Yes — No 4 NA 11 <br />MAINTENANCE: . <br />Well/Pump visible and protected from damage Yes No I NA n <br />Well/Pump free from excessive vegetation Yes Ijj No Li NA L 1 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IiI No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes jJ No n <br />Photograph taken and attached to record Yes T No <br />OTHER: . <br />Comments: <br />, <br />• <br />- \ <br />\ <br />k <br />i Inspected By: 4 ., Title: c/A <br />Received By: Date: