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R ' SAN JOAQUIN COUNTY A ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Pl IMP IMIQP1:r_T1nK1 r'U=nt[ 1 1c -r Addreps, .vPermi SRA Parameter/Standard Meets SJC Standards? Inction Date: sp : -7 WDC) s/4 ��13�� Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [v]' No ❑ NA ❑ No ❑ I Casing extends at least 12". above grade Yes W No ❑ NA ❑ NA Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ Permit drawing sufficient to locate well in future Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA ❑ No Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes D No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [j/ 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 ❑ - -- Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA _ — Air gap of at least (i" (same as pipe diameter) 1YesLj jNoLj INA MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ I NA Well/Pump free from excessive vegetation Yes Yf No ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well Yes No Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes No OTHER: Comments: If 'no' is selected, attach an accurate map to permit Inspected By: CkMTitle: V N dti 4, Received By: Date: