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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd PI IMP INSPFCTIC)N rFIFr W 1 ICT Address:Per #: 0 3 91 E, Gv-m ST -0 Ck- CJD S-1 _Dc � ` 6-o 6 Ins e do Date: o f�; �. Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ MISCELLANEOUS: Casing extends at least 12" above grade Yes No ❑ NA ❑ Yes Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ OTHER: Free of cracks/contiguous with annular seal Yes [Z No ❑ NA ❑ ° Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing IYes 0 No ❑ NA ❑ Seal between all pipe columns and casing Yes 2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [{� Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes W No ❑FNA EE] installed check valve or BFP device Yes No ❑❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA - Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA R✓ MAIN 1 tNANG1=: Well/Purnp visible and protected from damage Yes9 No ❑ NA Well/Pump free from excessive vegetation Yes J� No ❑ I NA MISCELLANEOUS: Permit drawing represents actual location of well Yes No Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes No OTHER: Comments: If'no' is selected, attach an accurate map to permit Inspected By: J Title: - I k� is fa - Received By: Date: MW nonn ail�dinna�