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R ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax; (209) 468-3433 Web; www.sigoy.orgfehd PI IMP INIGPF('Tlr)M P'_141=r 1C 114ZT Addr s h J - -- - —_—Permit#: V X I N QO P ?.3�0 Inspection D e: to, 1,2113 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Permit drawing represents actual location of well Casing extends at least 12"_ above grade Yes 91 No ❑ NA ❑ Yes &A Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ OTHER: Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes W No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes RZ No ❑ INA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes`[�] No ❑ lNo NA ❑ Chlorination port available and sealed properly Yes S6 ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [V -- Adequately installed check valve or BFP device Yes No El NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ - Air gap of at least 6" (same as pipe diameter) Yes El No ❑ 4NA MAINTENANCE: vveii/Fump vlsime ana protected from damage jYesU INo"INA" Well/Pump free from excessive vegetation IYes Uf INo ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes &A No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: / Inspected By: T (,>;Ak IVJU ITitle• `VISIrrr�•,rl,v,.. �1 ff&Mtf" A;UI I Received By: . I Date: