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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868_Eas-t-HazeltonAYenu�,� �kt2n. CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:.www.si.qov.orq/ehd 15UMP INSfYEGT FIEGK LIS Address:Perini >J 1x-1 J)9,&7 -t+ L� G k ��00 3--7�5b� Inspe tion ate: 1 /703 t i Parameter]Standard Meets SJC Standards? Comments/Measurements] Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes LA No ❑ NA ❑ _ Casing extends at least V above pedestal Yes M No ❑ NA ❑ Free of cracksJcontiguous 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 ® No ❑ NA ❑ Seal between all pipe columns acid casing Yes 9 No ❑_ NA ❑ Sounding tubelair vents sealed properly - Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes Q No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of wellhead Yes [4 No ❑ NA ❑ Adequately installed check valve or BFP device Yes [/ No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA [V Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 14 MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA El MISCELLANEOUS° Permit drawing represents actual location of well . Yes FA No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If 'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Zeceived Bv: Title: j Date: