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T 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.orglehd <br />PI IMP IAIgPPr'TlrlAl r Ur7r V I le -r <br />Addrey � � �" <br />ParameterlStandard <br />, ' ` � P�' V V 3 2 0 J Zfl( on . <br />Meets SJC Standards? Comments/Measurements/ d <br />Recommendations <br />GEMENT PEDESTAL: <br />Seal between all pipe columns and casing <br />Yes ® <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes ® <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes [✓1 <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes W <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes j0 <br />No ❑ <br />NA ❑ <br />Ie7ARIJAMY ZCAL: <br />Well is sealed between pump and casing <br />Yes 0 <br />No ❑ NA ❑ <br />Seal between all pipe columns and casing <br />Yes ® <br />No ❑ NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ NA <br />Chlorination port available and sealed properly 1yes <br />j I <br />No ❑ NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head <br />valve or within 3' of well head <br />es No ❑ <br />NA ❑Adequately <br />4andcheck <br />installed check valve or BFP devies <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 ❑ No ❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ No ❑ <br />NA [Jf <br />MAINTENANCE: <br />l/Vell/Pump visible and protected from damage <br />Yes � <br />No E] <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes V <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS.• <br />Permit drawing represents actual location of well <br />Yes 2 <br />No ❑ <br />If `no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes Ld <br />No ❑ <br />Photograph taken and attached to record <br />Yes <br />No R <br />OTHER: <br />Comments: / <br />Inspected By: <br />Received BV: <br />=u AOnn <br />s <br />Title: <br />Date: <br />