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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 1-86.8_East-11- aze.ItonAv-eLl.LLe,-S-t-Zcktat) CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigoy.orglehd — P[JMP INsp-EcTf flFGK iST -- --- Add ess: I .-� P� ery Vo o 3 -) _5 1 w �i Inspn ate: 111mll Parameter/standard Meets SJC Standards? Comments/Measurem entsl Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [A No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes kA No ❑ NA ❑ Graded to allow drainage away from casing Yes V No ❑ NA ❑ SANITARY SEAL: Well is sealed between. pump and casing Yes W No ❑ NA ❑ Seal between all pipe columns and casing Yes M No ❑_ NA ❑ Sounding tubelair vents sealed properly - Yes ❑ No ❑ NAM Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AMD BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within T of wellhead Yes No ❑ NA ❑ 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) Yes ❑ No ❑ NA 51 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes Sy. No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Vj No ❑ NA ❑ MISCELLANEOUS• Permit drawing represents actual location of well . Yes W No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes5Z No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments:/ nspected By: 0 Title: a \J l�Yvn /Vl 4i <1 I'� �i � �s1 deceived By: Date: n M 1-.11.