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G3 -.1 J 0 1-,I ),QUII\l Cojjj\`f"!' <br /> E111MRONIN/11ENIAL HEALTH DEPARTMIENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> T-cfephoi7e:(209)468-3420 f.-'-ax: (209)468-3433 1/f/eb:wv,11('j.si.qov.org/e11d <br /> PUNIP INSPECTM CHECK UIST <br /> Permit Inspection Daie.: <br /> Qyky-13�- (AkN cA Y"S �WRo E)-Sd,�VL Iwo -Z-611 <br /> I <br /> Paranneterf-Siandard Meets SJC Standards? <br /> eon nmentSllineas uren-,enc'S/ <br /> Reconimendatioils <br /> ICEMENIT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 14 No F1 NA M <br /> lCasing extends at least ,12" above grade Yes [4 No F1 NAE] <br /> Casing extends at least V above pedestal Yes No 0 NA El <br /> Free of cracks/contiguouswithth annularseal Yes iso o NT,Ei <br /> Graded to allow drainage away from casing Yes I TIo F7 <br /> I NAE1 <br /> SAMTARY SEAL. <br /> Well is sealed between pump and casing Yes INoE] INAD I <br /> Seal between all pipe COILInins and casing Yes I No [:1 INA <br /> SOLMCMng-Wbe/21k-vents sealed properly Yes No E:1 INA El <br /> Chlorination poll available and sealed properly Yes No E:1 INA❑ <br /> ,SAFVTIPLE TAP AND BACKFLOVOF PREVENTION: <br /> i Non-threaded sample tap between vkiell head and <br /> icheck valve or within T of well head Yes No j F IA 0 <br /> �N <br /> kdequately installed check valve or BFP device I Yes Ej No ❑ I NA El <br /> No cross coilnections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dorriestiG supply) Yes E] No I NA El <br /> Air gap of at least 6" (same as pipe diameter) I Yes..E] INoE]TNA d I <br /> MAI KITENANCE:-- <br /> Well/Pump visible and protected from darn2ge Yes ;No Fj INA El <br /> We!Purnp free from excessive vegetation Yes Et No 0 INA [I <br /> ,M[§GELLANEOUS-. <br /> Permit drawing represents 2I.CtUal IOCalti011 Of ktjell Yes <br /> i.Pern-,it drawing sufficient to locate viiell in fUture I Yes 11'no`is selected:attach 211 accurate map to permit <br /> Photograph taken and attached to record IYes 0 I.No ❑ <br /> OTHIER: <br /> II <br /> Inspected Cy: <br /> M N <br /> NJ —NJ <br /> Received 13y: (Date: <br />