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SAIII jOAQUINI C;ouiVTY <br /> ENV]RO11,f1VjEi\1TAj-HEALTH DEPARTMENT <br /> 1868 East Flazel"t-On Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 14ifeb:vv\kA1v.sjqov.orq/ehd <br /> PUNAP INSPECTION CHECK UST <br /> Address. <br /> ITI <br /> nsp tion <br /> 1_ <br /> I jD ate: <br /> 1-j - Ai�begSi),J ST 1 <br /> c 1e^.e#L1j -373S3 I I rO [100 <br /> II <br /> on, ments[MeaSUrementsi <br /> Parameter/Standard Meets SJC Standards? <br /> _Recommendations <br /> GEMENTPEDESTAL, <br /> (Dimensions of surface seal (2'x2'x4` minimum) Yes V No 0 NAE1 <br /> icasing extends at least 12" above grade ..Yes V NoEl NAF-1 ii <br /> Casing extends at )east 1" above pedestal Yes 2 No [I INA 0 <br /> Free of cracks/contiguous with annular seal Yes JZ NoEl NA 0 <br /> Graded to allow drainage away from casing IYes V NDO NA [1_j <br /> SANITARY SEAL: <br /> iVVell is sealed between punip and casing YesI No ff NA ❑ <br /> 'Seal between all pipe columns and casing Yes NA <br /> ;Sounding tube/air vents sealed properly Yes V No F-I NAF-1 <br /> I <br /> 'Chlorination port available and sealed properly Yes 2 No Ej NA [:1. <br /> SAIVIPLE TAP AND BACKFLOAJ PREVENTION. it <br /> lNon-threaded sample tap between well head and <br /> chieck valve or within 3' of well head Yes U No L7 INA 0 li <br /> jAdequately installed check valve or BFP device Yes V No F-1 NA El <br /> �I"No cross connections (ex.- chemical feeders <br /> !hooked to distribution system/ag flood irrigation <br /> jfrorrl domestic supply) Yes E] No ❑ NA I� Ij <br /> 'Air gap of at least 6` (same as pipe diameter) I YesEl INoE1 NAV I <br /> 1MAINTENANCE: <br /> iVVell/Pujiip visible and protected from damage ±/es SZ INo 0 NA F I <br /> �11 -np free from excessive vegetation <br /> Well/Pui _s Sf No 0 NAE1 I <br /> 11,MISCELLANEOUIS: <br /> Permit drawing represents actual location of well Yes No <br /> Permit drawing sufflicient"Lo locate well in future Yes No ❑ 1-1—no'is selected,attach an accurate Map to permit <br /> Photograph taken and attached to record IYes No ❑ <br /> '0 T H E R, <br /> Coinments., <br /> PIZ )'PNSQv(j� ` i <br /> J <br /> h-ispected Bv: aA Title: Ar3ij+5z,-,T- <br /> bReceived 13y: Date: <br /> rZI-A norm <br />