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'0ANJOAQUI' COUNTY <br />BvIRONIMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />7eb-aphoi7e: (209) 468-3420 Fax: (209) 468-34303 14/bb: W\fNj.sjgov.oi- <br />_g1ehd <br />\A� - 'A,'M_ kOW_>Auk +4,+MP4NSPECT1ON CHEGI/C LIST <br />Address: <br />Pa ranieter/Standard Meets SJC Standards? <br />P e r m i V.n: Inspection Date: <br />\,\)? ri -23 a, 0 Oon III h <br />E� <br />Coiiiriieiitq/il4easLi-enints/ <br />Recorni-IleildatIO11S <br />GEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4' minimum) <br />YesEj <br />No F] <br />NA Ej <br />Casing extends at least 12" above grade <br />YesEl <br />No E] <br />NAE1 <br />Casing extends at least 1" above pedestal <br />Yes E]]NoF] <br />NAE1 <br />Free of cracks/contiguous with annular seal <br />YesEl <br />No 0 <br />NAEJ_ <br />Graded to allow drainage away from casing <br />YesEl <br />No[] <br />NAEJ_ <br />SANITARY SEAL: <br />Well is sealed between Pump and casing <br />IYes 0 <br />INoE1 INA <br />E] <br />I <br />Seal between all pipe colun-ins and casing <br />YesE] <br />No[_1 INA[—] <br />I <br />SOUndingUlbe/air vents sealed properly <br />YesE] <br />No E] INA <br />[:1 <br />1 <br />Chlorination poll available and sealed pro peri` <br />I YesEl <br />INoE1 INA <br />[I <br />I <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3" of well head <br />Yes [_1 <br />NoE_j I <br />NA ❑ <br />Adequately installed check valve or FFP device <br />Yes 0 <br />No ❑ <br />INA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution systenilag flood irrigation <br />from om domestic SLII:)Ply) <br />YesEl <br />jNoF❑I <br />NA [_1 <br />Ali- capofat least- 6" (same as pipe diameter <br />IYes El <br />INoE]j <br />NAE1 <br />I <br />MAINTENANCE: <br />Well/Pun-Ip visible and' protected from damage <br />Yes El <br />No F <br />NA ❑ <br />Well/Pum p free from excessive vegetation JYesE1 <br />NoEj <br />NA [I <br />FVII§CELLANEOLIS: <br />;Permit drawing represents actual location of well <br />IYes [I <br />I NoEl <br />lf'no'is selected, attach, an accurate map to permit <br />Pern-lit drawing sufficient -Lo locate well in fuiure <br />es El <br />No El <br />Photograph taken and attached to record <br />N(es <br />OTHER: <br />Coni) dents: <br />IF � <br />Inspected BY: Title <br />Received By: IDate: <br />