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a ! ' SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.ora/ehd PI iMP 1MQD1=rT1nK1 PUZ=I�V 11e -r AddressdenleAkInsp : AS), 1� Parameter/Standard rj.�� Meets SJC Standards? tion ate: In ao .3 S � r z / Comments/Measuremen s/ Recommendations CEMENT PEDESTAL: 1 Adequately installed check valve or BFP device Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at (east 12" above grade Yes [� No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [0 Yes V No ❑ No ❑ NA ❑ NA ❑ Free of cracks/contiguous with annular seal Graded to allow drainage away from casing No ❑ Yes j� No ❑ NA ❑ SANITARY SEAL: No ❑ NA ❑ Well is sealed between pump and casing Permit drawing represents actual location of well Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes Yes No ❑ NA ❑ Sounding tubelair vents sealed properly OTHER: Yes No ❑ NA ❑ Chlorination port available and sealed properly a wwra■ n YesNo ❑ NA 1/1 ZPAIVIr1-t JAI' ANN bAU KI'LUI/V PREVENTION: ' Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ 1 Adequately installed check valve or BFP device Yes No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ TRNA Air gap of at least 6" (same as pipe diameter) Yes ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes�('] No ❑ lf'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes (Z No ❑ OTHER: Comments: inspected By: i Title: & t4 • ks;j Received By: Date: