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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.org/ehd P1 IMP INSPPrTirW r W=1-te'1 le -r Address:/ Sr. _ •vPermit#: g�ate: 9lb 4 • CO ARA -L HULLOLJ /Z� I�� Rdb7ia$a is jI Inspection 11 Parameter/Standard Meets SJC Standards? Com ments/Measurements/ Recommendations CEMENT PEDESTAL: Non -threaded sample tap between well head and check valve or within 3' of well head Yes V No ❑ Dimensions of surface seal (2'x2'x4" minimum) Yes V 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 cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes Qj. No ❑ NA ❑ SANITARY SEAL: NA ❑ MISCELLANEOUS: 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 ❑ No ❑ NA �] Chlorination port available and sealed properly Yes Fu i No f-1 NA 1-1 SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes V No ❑ NA ❑ Adequately installed check valve or BFP device Yes2 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 Q/ MAINTENANCE: Well/Pump visible and protected from damageYes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes W No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well es 9 No ❑ if `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future ]Yes es No ❑ Photograph taken and attached to record No ❑ OTHER: Comments: 11, inspecte� Received Gu n-�)nn sv 'title: E-01 /Ajj l'j l -f � Date: