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�l Y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9 868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd PI IRnP IAIRPPr*T1r'1K1 r%Wr=r'ie i ie -r Address; , ,vPe t#. [nspe tion ate: c�P WY&D-3s6l 6 ID Parameter/Standard Meets SJC Standards? Comments/Measuremen / Recommendations GEMENT PEDESTAL: No ❑ NA ❑Seal Dimensions of surface seal (2'x2'x4" minimum Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing No ❑ NA ❑Seal between all pipe columns and casing iYesM ® No ❑ NA ❑Sounding tube/air vents sealed properly V1 No ❑ NA ❑Chlorination pori available and sealed properly ❑ No ❑ NA Wj SAMPLE TAP AND 13ACKI;LOW PREVENTION Non -threaded sample tap between well head and check valve or within 3' of well head Adequately installed check valve or BFP device No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply Air gap of at least 6" same as pipe diameter) MAINTENANCE: VVe11/Pump visible and protected from damage Well/Pump free from excessive vegetation MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: Yes ❑ I No ❑ INA Yes ❑ INo ❑ INA V1 Yes Lj No ❑ INA Yesa INo R INA Yes 1,O jNoLjjNA Yes Lfl I No ❑ I NA Yes ® JNo ❑ Yes No ❑ If `no' is selected, attach an accurate map to permit Yes F14 lNo I-1 Received BV: Mu n"2nn Title: (_ Date: