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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8_East.HazelfonAv-enu_e, Sfszckto-n, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orcl/ehd Address: Perm �i#O Inspglotio ate: O Com► :57-o cK �, i.� 11� �� 3 �1 � (c`/o 8 r Parameter/Standard Meets BJC Standards? CommmentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes W No ❑ NA ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ NA ❑ Casing extends at least 1" above pedestal Yes 9 No ❑ NA ❑ NA Q Free of cracks/contiguous with annular seal Yes W No ❑ NA ❑ NA �( Graded to allow drainage away from casing Yes U No ❑ NA ❑ No ❑ SANITARY SEAL: Well is sealed between. pump and casing Yes U - No ❑ NA ❑ Seal between all pipe columns and casing Yes Z No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA Q Chlorination port available and sealed properly Yes ❑ No ❑ NA �( SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA J( Adequately installed check valve or BFP device Yes kA No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA bA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 5✓ MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes V No ❑ NA ❑ MISCELLANEOUS - Permit drawing represents actual location of well . Yes No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photoaraph taken and attached to record Yes No ❑ OTHER: Comments: l Inspected By: r&Q Title: fj/I part ll'1.Pi41 6 alk kf Received By: Date: ,,,.,a 1-1