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USAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Vlleb:vMAv.slgov.orq/ehd <br /> _ pe PUWIIP MPEG T ION CHECK LIST <br /> �_ <br /> Address: — —� — Permit=: Instion Date <br /> 4 M' L A-V Wc4 �,l Poa376 yq Zs/i¢ <br /> omments/ll�easurements/ <br /> PararneterlStandard Meets SJC Standards? CRecommendations <br /> ,CEI1rr1ET4If' PEI�E�TAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes W No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes NA ❑ <br /> Casing extends at least 1" above pedestal IYes No ❑ NA ❑ <br /> Free of cracks/Contiguous with annular seal Yes © No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [✓] No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes R No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes © No ❑ INA ❑ <br /> ;Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [v�' <br /> Chlorination port available and sealed properly IYes 9 No ❑ NA ❑ <br /> SAMPLE TAP ANLL BACKFLOW PREVENTION: <br /> ;Non-threaded sample tap between well head and <br /> check valve or within 3' of well head YesU No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes LM No ❑ NA ❑ <br /> �No cross connections (ex: chemical feeders <br /> (hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ [No ❑ NA <br /> !Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ NA [Y <br /> IMA1NTENANCE: <br /> Well/Pump visible and protected from damage o ❑ INA ❑ <br /> �Well/Pump free from excessive vegetation IYes FV1 INo ❑ INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 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 VINo ❑ <br /> iOTHER: <br /> C0111rnents- — — <br /> � P <br /> Inspected By: - -- -- Title: 14` Asdl r i , <br /> I <br /> I�Received By: Date: <br /> 1=u n nn a�•i �n4c <br />