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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -- - - 1-868_East_Hazelto.n_Av_en-ue,_StQclktQq-, CA 95205-6232 _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd Pl IM— P IffPF-CTF0-WGHE-GK-LIQ I -- Address: c (�U� _TTL_Elj� � Per i cc3' 3 Ins a tion ate: la o i� Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [d No INA ❑ Casing extends at least 12" above grade Yes 5X No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [j No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 12 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ _ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes KA No ❑ NA ❑ 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 E]NA Ff 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) IYes ❑ No ❑ INA ❑ Air gap of at least 6" (same as pipe diameter) IYes ❑ INo ❑ INA MAINTENANCE: Well/Pump visible and protected from damage Well/Pump free from excessive vegetation Yes ko Yes Fv-r No ❑ No ❑ NA ❑ NA El MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ If '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 U No ❑ OTHER: Comments: Inspected By: Title: 14. IDste- Received By: nM4 1-4 C