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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.orgiehd <br />SAX- \ P161.14P INSPECTION CHECK LIST <br />Address: <br />t., CON4-K1/4&'''CV1' CI— \l'\/ ' S aq Lek. "1 -' 5 <br />Permif#: <br />Vi Cit)V\ \ S l- <br />comments/Measureninisepnetseitten Date:* ParameterlStandard <br />i <br />M Meets SJC Standards? Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x21x4" minimum) Yes [1j No I I NA n <br />Casing extend at least 12" above grade Yes r--\-1 No NA 17 _ <br />Casing extends at least 1" above pedestal Yes I . No NA <br />Free of cracks/contiguous with annular seal Yes \, No) I NA 17 <br />Graded to allow drainage away from casing . Yes iicl No n _NA n <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 0- - No NA <br />Seal between all pipe columns and casing . Yes ] No n NA El <br />Sounding tube/air vents Sealed properly Yes E No -7 NA p <br />Chlorination port available and sealed properly Yes n No) I NA rj <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 No) I NA — <br />Adequately installed check valve or BFP device Yes E No n NA Ni <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes No -A NA Ej <br />Air gap of at least 6" (same as pipe diameter) Yes — No) I NA 0 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No I I NA H . . <br />Well/Pump free from excessive vegetation _ Yes 0 No ri NA E <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes \II No ri . <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No E <br />Photograph taken and attached to record YesN11 No I I <br />OTHER: <br />Comments: <br />• <br />, <br />• <br />, <br />\\ \N fik <br />Inspected By: Li \ I, \ \ ‘ . <br />Title: S(A. tvoc..-_.. il <br />Received By: <br />I Date: I <br />11/n4 rnr,IC