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SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone. (209) 468-3420 Fax: (209) 468-3433 Web; www.sigov.orq/ehd AI I11/1D 1K1(Z1DL::t--r1r-iAi r%L1cr+r� r re --r Address' Q r G GS R Parameter/Standard ,vPermi --A-T-4ko p Meets SJC Standards? lnspe'tion ate; w V o o 3 6 jab nq7� 1< � CommentslMeasurementsl Recommendations CEMENT PEDESTAL.: between ump and casing Yes © No ❑ NA ❑ Dimensions of surface seal 2'x2'x4" minimum Yes Q JNoEj NA ❑ vents sealed pro erly WY Casing extends at least 12" above grade I Yes Q jNoE1 INA ❑ Yes Casing extends at Ieast 1" above pedestal Yes [0 No ❑ I NA ❑ Free of cracks/contiguous with annular seal Yes [2 1 No ❑ NA ❑ Yes Graded to allow dminaaP awav frnm r acinrY Vo, rV ni„ r—r At n r—i No ❑ SEAL:aled between ump and casing Yes © No ❑ NA ❑ een all pipe columns and casing Yes No ❑ NAtubelair vents sealed pro erly WY Yes Q No ❑ NAn port available and sealed properly Yes No ❑ NA ❑AP AND BACKFLOW PREVENTION: ed sample tap between well head and— check valve or within 3' of well head Yes No ❑ NA ❑ Adequately installed check valve or BFP device JYes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply Yes ❑ No El Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ I NA Fl-�' MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes P1 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: Inspected By: CLA Sn Title: �noa+A-n Received By: Date: =u A -,;.nn