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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> _ J PUIVIP INSPECTM CHECK LIST <br /> Address: a Permit#: Inspection Date: <br /> Zoo �� 0.52 0 b 0 1, <br /> Parameterl,fandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes KI I No ❑ I NA❑ <br /> Casing extends at least 12" above grade AYesNo ❑ NA❑ <br /> Casing extends at least 1" above pedestalNo ❑ NA <br /> Free ofcracks/contiguous with annular sealNo ❑ NA❑Graded to allow drainage away from casingNo ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes d No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly I Yes ❑ No ❑ NA <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within T of wellhead Yes ❑ No ❑ NA 4 <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No [j NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA U <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes j INo ❑ NA [] <br /> MI§CELLANEOUS: <br /> Permit drawing represents actual location of well IYes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> I <br /> Inspected By: Title: 4d4gC <br /> Received By: Date: <br />