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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefepshone:(209)468-3420 f=ax: (209)468-3433 Web:vwvw.sigov.orq/ehd <br /> DUMP INSPECTION CHECK LIST <br /> P:ddress: Permit#.: Inspection Date: <br /> IINZ Tl <br /> Parameter/Standard Meets SJC Standards? omme is/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No El El <br /> Graded.o allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY"SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination poll available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes No ❑ �NA ❑ <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 ❑ Nod NA❑ <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ jNoE1 NA <br /> MAINTENANCE: <br /> Well/Pump,visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLA.NECLIS: i <br /> Permit drawing represents actual location of well Yes No ❑ <br /> iPermit drawing sLlfficient 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 /> y�.��`4��C� ��,� S'��►�.@mac. - 'C FAQ . <br /> Inspected By: Title: <br /> Received By: Date: <br />