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F t R <br />Y SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />F PI IMP INIGPPI-TIrim r-Lj=r-w i ic�-r <br />Address: R w <br />Parameter/Standard <br />�! t !J G j vpw r &0 31 Z lO pe 2l Dayte: <br />�d <br />Meets SJC Standards? CommentsIMeasurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Non -threaded sample tap between well head and <br />G heck valve or within 3' of well head <br />Yes ❑ <br />No ❑ <br />Dimensions of surface seal (2'x2'x4" minimum)Igor <br />FO <br />I Yes <br />❑ <br />Casing extends at least 12" above grade <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />❑Casing <br />extends at least 1uabove pedestal <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />❑Free <br />of cracks/contiguous with annular seal <br />MAINI"ENANCE: <br />❑Graded <br />to allow drainage away from casing <br />Well/Pump visible and protected from damage <br />YesV <br />❑ <br />SANITARY SEAL: <br />Well/Pump free from excessive vegetation <br />Yes <br />Well is sealed between pump and casing <br />Yes M <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Sounding tubetair vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA [✓1 <br />Chlorination port available and sealed properly <br />Yes ❑ <br />No ❑ <br />NA <br />[H►yrr'-e 1Hr AINW 1:51AU I-LUVV FKtVLN[IUN: <br />Non -threaded sample tap between well head and <br />G heck valve or within 3' of well head <br />Yes ❑ <br />No ❑ <br />NA [�( <br />Adequately installed check valve or BFP device <br />I 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 ❑ <br />No ❑ <br />NA O <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />MAINI"ENANCE: <br />Well/Pump visible and protected from damage <br />YesV <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />- <br />Permit drawing represents actual location of well <br />Yes <br />No <br />o'is selected , attach an accurate map topermit <br />Permit drawing sufficient to locate well in future <br />Yes Q <br />No <br />Iff <br />Photogra h taken and attached to record <br />Yes [11� <br />No <br />OTHER: <br />Comments: <br />Inspected By: s <br />Title: G ' ► I ' SS1S <br />Received By: <br />Date: <br />Cu n�nn <br />