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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; www.sjgoy.ora/ehd Pi IMia IAiSP1='r TIr)hI I icT Address: Per t Inspe tion ate e f1 C R r l� CT-Siac,lCib�► a&D3"75qt f� 2�/ Parameter/standard Meets SJC Standards? Comments/Measurements] Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4n minimum) Yes ® No ❑ NA ❑ - Casing extends at least 12" above grade Yes V No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of crackstcontiguous with -annular seal Yes © No ❑ NA ❑ Graded to- allow drainage away from casing Yes © No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing YesWo[Djj ❑ - Seal between all pipe columns and casing Yes M ❑ Sounding tube/air vents sealed properly Yes ❑ [v�'' Chlorination port available and sealed properly Yes [� ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑MNoE0J NA ❑ rio S�p'� 4°-0 Adequately installed check valve or BFP device Yes ❑NA ❑ � r v vi -6 { C � No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑NA Ek Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 0 MAINTENANCE: Well/Pump visible and protected from damage IYes Well/Pump free from. excessive vegetation Yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: 1j'�' 5C-Y'qle 4 Inspected By: Received Bv: No ❑ INA LJ No ❑ INA ❑ Yes 6UAN'o Yes No Yes lel No lf'no' is selected, attach an accurate map to permit Title: 0'1111 fD.'1/Yij,�,�� k k ay Date: