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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />P61-14P INSPECTION CHECK LIST <br />ACIT1r-e7S-S7-- <br />1 eiC71 CO 1) - tn;6\1`) -'1/4'sJ SL., \ALS ( q 6C2`5 (Z- <br />Permit#: <br />‘,QR 0 0-cik -& 3 <br />Inspection Date:. <br />051okli-OA <br />Parameter/Standard Meets SJC Standards? Cornments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes -j No I I NA n <br />Casing extends at least 12" above grade Yes dl No ri NA E <br />Casing extends at least 1" above pedestal Yes I J No f NA fi . <br />Free of cracks/contiguous with annular seal Yes l___1 No Irl NA fi <br />Graded to allow drainage away from casing Yes LI No INA NoT Ft TO .1c;) 1-"t il-- <br />SANITARYSEAL: \u,k13 ok1 /4 <br />Well is sealed between pump and casing _Yes n• No It NA fi fo4t„ s OW i:- PrOi -.›(--fri. <br />Seal between all pipe columns and casing Yes fi No n NA rj- L. <br />Sounding tube/air vents Sealed properly - Yes I I No I I NA lEj 1 1 <br />Chlorination port available and sealed properly Yes No LI NA ---J <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 n No NA <br />- Adequately installed check valve or BFP device Yes fi No n NA I- <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes I I No n NA <br />Air gap of at least 6" (same as pipe diameter) Yes fi No I I NA Li <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes \I No ri NA. 1-1" <br />Well/Pump free from excessive vegetation _ Yes -4 No I I NA L <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No ri <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No fi <br />Photograph taken and attached to record Yes No C <br />OTHER: <br />Comments: <br />_A.L.,(.---...rs cr, <br />.. <br />. , <br />• <br />, <br />. k nk <br />Inspected By: A,1 ‘ % 1 <br />I <br />Title: <br />Received By: Date: <br />fltfl4 inn.1 c