Laserfiche WebLink
T 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.sigov.org/ehd <br />4 P1 rnnn tr lcpl=rT1rnwt ruat�Lr I lc�,- <br />Address: !! <br />` i�W , �7 nig <br />Parameter/Standard <br />t1 ,p <br />P ©0.385`q q1 108 �` na: <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />No ❑ NA [1� <br />Chlorination port available and sealed properly Yes ❑ <br />No ❑ INA <br />Dimensions of surface seal (2'x2'x4" minimumMNoElNA <br />Non -threaded sample flap between well head and <br />check valve or within 3' of well head <br />Yes ❑ <br />❑ <br />Casing extends at least 12" above grade <br />Adequately installed check valve or BFP device <br />NA❑Casing <br />extends at least V above pedestal <br />NA ❑ <br />NA❑Free <br />of cracks/contiguous with annular seal <br />No ❑ <br />NA 0 <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [r� <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes V <br />Well is sealed between pump and casing <br />Yes ® <br />No ❑ <br />NA ❑ <br />Ord, Wt-_Lween au pipe columns ana casing Yes <br />No J_f NA Lj <br />Sounding tube/air vents sealed properly Yes ❑ <br />No ❑ NA [1� <br />Chlorination port available and sealed properly Yes ❑ <br />No ❑ INA <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample flap between well head and <br />check valve or within 3' of well head <br />Yes ❑ <br />No ❑ <br />NA [A <br />Adequately installed check valve or BFP device <br />Yes.0 <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 0 <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA [� <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes V <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 />lf'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes © <br />No ❑ <br />Photograph taken and attached to record <br />Yes L6 <br />No ❑ <br />OTHER: <br />Comments: <br />Received BV: <br />E:u A WIn <br />rol <br />Title: �'� ASs(s <br />Date: ' <br />