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A <br />T SAN JOAQUIN COUNTY <br />ENv1RONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax; (209) 468-3433 Web; www.sjgov.oiq/ehd <br />PI Illrtp 1MQ131=r-nrlA1 rLJar%V r lcrr- <br />Address: <br />00l i LirJDEj <br />ParameterlStandard Meets SJG Standards? <br />Inspe on to <br />TVrpo38 o8cyon 12 <br />Comments/Measurements( <br />Recommendations <br />CEMENT PEDESTAL: <br />Non -threaded sample tap between well headtand <br />check valve or within 3' of well head <br />❑ <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes L( <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yed © <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes ® <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes Q <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well/Pump free from excessive vegetation <br />Yes <br />Well is sealed between pump and casing <br />Yes ©No <br />❑NA <br />❑ <br />Oed, uULween all pipe columns ana casing Yes U No (J NA <br />Sounding tubelair vents sealed properly Yes ❑ No ❑ NA <br />Chlorination port available and sealed properly Yes ❑ No ❑ NA <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well headtand <br />check valve or within 3' of well head <br />❑ <br />-- <br />NA <br />Adequately installed check valveor BFP devi❑ <br />NA❑No <br />cross connections (ex: chemical feedershooked to distribution system/ag flood irrigatifrom domestic sup ly) <br />❑ <br />NAAir <br />gap of at least 6" (same as pipe diameter)❑ <br />NA WZ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes ® <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No ❑ <br />No ❑ If `no' is selected, attach an accurate map to permit <br />No ❑ <br />Permit drawing sufficient to locate well in future <br />Yes <br />Photograph taken and attached to record <br />Yes <br />OTHER: <br />Comments: <br />Received Bv: <br />cu n•:)nn <br />'title: <br />Date: <br />