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s � <br />' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 468-3420 Fax. (209) 468-3433 Web; www.sjgov.orq/ehd <br />PI IMP IAICP;:rT1r7tK1 [%Wi=r`tr i ie -r <br />---- ----- — --------_._._ �. <br />Address <br />3 w Lr <br />Perini <br />060373 0 6 <br />= <br />Inspe ion ate: <br />o ,3� <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />GEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes Q <br />No ❑ <br />NA ❑ <br />No ❑ <br />Casing extends at least 12" above grade <br />IYes [a' <br />No ❑ <br />NA ❑ <br />NA <br />Casing extends at least 1" above pedestal <br />Yes EZ <br />No ❑ <br />NA ❑ <br />MAINTENANCE: <br />Free of cracks/contiguous with annular seal <br />Yes ® <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes <br />No ❑ <br />NA ❑ <br />NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes [�' <br />No ❑ <br />NA ❑ <br />Yes <br />Seal between all pipe columns and casing <br />Yes ® <br />No ❑ <br />NA ❑ <br />OTHER: <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA M <br />�,niorination port available and sealed properly <br />1YesU <br />INoLJINA <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes j <br />No ❑ <br />NA <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ <br />NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes E]No <br />❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) IYes <br />❑ <br />No ❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />ED <br />Well/Pump free from excessive vegetation <br />Yes �+Noo <br />❑ <br />NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No <br />Permit drawing sufficient to locate well in future <br />Yes <br />No <br />Photograph taken and attached to record <br />Yes <br />No <br />OTHER: <br />Comments: <br />Inspected By: 11CW ( N sl <br />Received <br />Cu n)nn <br />If 'no' is selected, attach an accurate map to permit <br />Title: 61V I r -D ^ <br />Date: <br />Nie,/tt <br />A/te 11M.1G <br />