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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.sigov.orq/ehd PI IMP INgPF=rTIf'W rt4r=rV I ICT Address: Pr tV / F M Pr7 ` C C Parameter/Standard Meets SJC Standards? . �TRecommendations Perm ? &oJ ` 6'6 l�s�e�on� 1te. VO Cornments/Measurements/ CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No EI INA ❑ No ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ No Casing extends at least 1n above pedestal Yes [2 No ❑ NA ❑ Yes Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes M No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes © No ❑ NA ❑ Seal between all pipe columns and casing Yes [2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes L4 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes lNoD NA ❑ Adequately installed check valve or BFP device Yes LZ 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 6" (same as pipe diameter) Yes ❑ No ❑ NA 67 MAIN 1 tNANGL: Well/Pump visible and protected from damage Yes [� No ❑ NA Wel]/Pump free from excessive vegetation Yeso No ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well Ye 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: �� Title: Received By: Date: cu Al)nn