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FLAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 t=ax: (209)468-3433 Web;wln/vv.sigov.orq/ehd PUNIP INSPECTION CHEr'K LIST Address: ( M UAJ P-0 A•VE -S To e kTaA/ L"A/ � ! � V i�� e�� Parameter/StandardI Meets SJC Standards? CommentslAreasurements/ Recommendations .CEMENT PEDESTAL: i (Dimensions of surface seal (2'x2'x4" minimum) Yes No F-1 NA❑ Casing extends at least 12" above grade Yes [ No ❑ INA ❑ Casing extends at least V above pedestal Yes R I No ❑ INA❑ Free of cracks/contiguous with annular seal Yes ® No ❑ INA ❑ i Graded to allow drainage away from casing Yes to No ❑ INA ❑ II ANITARY SEAL: II Well is sealed between pump and casing Yes Ej No ❑ NA ❑ 1 Seal between all pipe columns and casing Yes No ❑ NA ❑ g ;Sounding tubetair vents sealed properly Yes ❑ No ❑ NA Q Chlorination port available and sealed properly Yes ® No ❑ NA ❑ j SAi111PLE TAP AND BACKFLOW PREVENTION: i Non-threaded sample tap between well head and check valve or within 3' of well head Yes No ❑ INA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation ;from domestic supply) Yes ❑ No ❑ NA jAir gap of at least 6" (same as pipe diameter) Yes ❑ INoD NA [Z Ij MAINTENANCE: IWell/Pum visible and protected from damage Yes No NA i p p g � ❑ ❑ Well/Pump free from excessive vegetation Yes Wf INoDINAD MISCELLANEOUS: Permit drawing represents actual location of well Yes 21 No ❑ Permit drawing sufficient to locate well in future (Yes 0 No ❑ li'no'is selected,aitach an accurate map to permit (Photograph taken and attached to record Yes V No ❑ f 101 HER: Comments: rr 1 I S Q c C2 CiSL•G re�e SLv✓r+✓ti,r, -N, Qe i I II inspected By: f ,,Received By: Date: Cu n,)nn ar� io,�ar.