Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1368 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Terephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgiehd <br />INSPECTION CHECK LIST <br />Address: <br />vat.e- CVNViki.ic Al-- iq . •c,TI. (\) CA- S -z-‘ 3 i <br />Permit#: <br />\1,303 -16 -13 <br />---, <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes No n NA E <br />Casing extends at least 12" above grade Yes iJJ No NA LI <br />Casing extends at least 1" above pedestal Yes No LI NA E 1 <br />Free of cracks/contiguous with annular seal Yes NA n No] I , <br />Graded to allow drainage away from casing . Yes R No LI NA F <br />SANITARY 'SEAL: <br />Well is sealed between pump and casing Yes 4- No LI NA <br />Seal between all pipe columns and casing Yes E No Fl NA Id" <br />Sounding tube/air vents Sealed properly - Yes LI No LI NA <br />Chlorination port available and sealed properly Yes q No LI NA I I <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 LI No NA al <br />Adequately installed check valve or BFP device - Yes LI No LI NA 0 <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA I <br />Air gap of at least 6" (same as pipe diameter) Yes n No n NA j <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes RI- No n NA <br /> <br />Well/Pump free from excessive vegetation Yes N No LI NA H 1 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No n <br />If no is selected, attach an accurate map to permit !Permit drawing sufficient to locate well in future Yes No — <br />Photograph taken and attached to record Yes I No n <br />OTHER: <br />Comments: <br />1 <br />— <br />1 TM L( . Wc..)-C(60 S t•iti --• <br />• <br />, , ‘. <br />Inspected By: \\\ Ni ‘A\ <br />. <br />Title: Vs)\. Qc <br />Received By: Date: <br />n .1 1,1114 c