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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1.86.8_East_Hazelton-Av-enue, S-toekto-o., CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />LL' hil- r <br />Address: <br />Cu i �-�- �-� Pr C P <br />Permf <br />o o 3 6 96 <br />Inspe tion ate: <br />!o X30 pate: <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes ❑ <br />No 9 <br />NA ❑ <br />rQ c. % s <br />Graded to allow drainage away from casing <br />Yes &Z <br />No [INA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes [A <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes 9 <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly - <br />Yes ❑ <br />No ❑ <br />NA ['►� <br />Chlorination port available and sealed properly <br />Yes ❑ <br />No V( <br />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 <br />Yes ❑ <br />No EZ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes ® <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />IYes ❑ <br />No ❑ <br />NAM <br />Air gap of at least 6" (same as pipe diameter) <br />jYesE1 <br />No ❑ <br />NA M <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />I Yes Q <br />JNo ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />I Yes rV( <br />No ❑ I <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />. Yes [v <br />No ❑ <br />If 'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes [' <br />No ❑ <br />Photograph taken and attached to record <br />Yes M <br />No ❑ <br />OTHER: <br />Comments: f <br />,�� S ��► l Cr��., °CSC& Aez I , U Iska I-ej (-Ll cvj s <br />Inspected By: t� <br />Title: <br />�4 / <br />Received By: <br />Date: <br />-- In 4 1 <br />