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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.sLciov.orq/ehd Pt rnrtc+ wQDE:�r--rir9n► r4ur7, ►r ► icrr AIddress• Parameter/Standard ins on D te: o-7 6 l2a Meets SJC Standards? Comments/Measurementsl Recommendations GEMENT PEDESTAL: _ NA U •• Seal between all pipe columns and casing Yes [V Dimensions of surface seal (2'x2'x4" minimum) Yes =No ❑ NA ❑ Casing extends at Least 12" above grade Yes 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 No ❑ NA ❑ SANITARY SEAL- znr.tt ❑Permit If 'no' is selected, attach an accurate map to permit drawing sufficient to locate well in future uc,.vvct�t, NulI1P a[lu c;a5ing Yes No LJ NA U •• Seal between all pipe columns and casing Yes [V No ❑ NA r-1Sounding tubefair vents sealed properly Yes ❑ No NA ❑ Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Yes No ❑ Non -threaded sample tap between well headqancheck valve or within 3' of well head Yes ❑ No NA❑Adeauately fnstR11prl rhark iradmm nr PPID rlotrV-- r—Y AT- " r,tA r—i No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA EV Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [Z MAINTENANCE: e Well/Pump visible and protecteEvegeEtation Yes No ❑ NA ❑ Well/Pump free from excessive Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yejs:No ❑Permit If 'no' is selected, attach an accurate map to permit drawing sufficient to locate well in future YeNo ❑ Photograph taken and attached to record Yes No ❑ OTHER: C omments. Inspected By: at, i N.3 0 Title: Received By: jDate. r -u A -inn