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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PI IMP INgPPf'TInK1 r°WC:r1V i 1Q -r <br />Address: <br />�.� <br />Parameter/Standard <br />- -- - _ --- <br />Permit#: lnspec 'on D te: <br />0 10 <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />NA <br />r <br />Adequately installed check valve or BFP device Yes <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes � <br />No ❑VE0j <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes ❑ <br />Casing extends at least 12" above grade <br />Yes © <br />No ❑Casing <br />Air gap of at least 6" (same as pipe diameter) Yes ❑ <br />extends at least 1" above pedestal <br />Yes [� <br />No ❑Free <br />MAINTENANCE: <br />of cracks/contiguous with annular seal <br />Yes <br />No ❑Graded <br />NA ❑ <br />to allow drainage away from casing <br />Yes © <br />No ❑ <br />No ❑ <br />SANITARY SEAL: <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Well is sealed between PUMP and casing <br />Yes 2 <br />No ❑ <br />NA E]Seal <br />Yes <br />between all pipe columns and casing <br />Yes [? <br />No ❑ <br />NA ❑ <br />OTHER: <br />Sounding tube/air vents sealed properly <br />Yes <br />No F]NA <br />❑ <br />Chlorination port available and sealed properly <br />Yes ❑ <br />No ❑ <br />NA [EV <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 ❑ <br />No ❑ <br />NA <br />r <br />Adequately installed check valve or BFP device Yes <br />No ❑ <br />NAE1 <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes ❑ <br />No ❑ <br />NA 0 <br />Air gap of at least 6" (same as pipe diameter) Yes ❑ <br />No ❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes V <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes U <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 [A <br />No ❑ <br />OTHER: <br />Comments <br />+�,� 10 L <br />Received By Date.• <br />C:u n-�Inn <br />