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Y ` SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web, www.sigov.orq/ehd <br />PI IMI, Iruc13FZ("-T1nK1 j ic,- <br />Address: fes, <br />li �jCT(Q l� �•,� <br />Parameter/Standard <br />' Perrrtit J ©ge tion Date: <br />7 <br />�w_ j (-' <br />Meets SJC Standards? Cornments/Measurements <br />Recommendations <br />CEMENT PEDESTAL: <br />Sealbetween all pipe columns and casing ® <br />Adequately installed check valve or BFP device <br />NA ❑ <br />Dimensions of surface seal (2'x2'x4" minimum <br />Yes ® <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes® <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes Q] <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [ ] <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />El <br />If `no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Well is sealed between pump and casing YesFN-ofM- <br />!Yes <br />Non -threaded sample tap between well head and <br />GIvalve or within 3' of well head <br />NA ❑ <br />Sealbetween all pipe columns and casing ® <br />Adequately installed check valve or BFP device <br />NA ❑ <br />Sounding tube/air vents sealed properly IYes ❑ <br />No ❑ <br />NA ✓ <br />Chlorination port available and sealed properly IYes V <br />No ❑ <br />NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />GIvalve or within 3' of well head <br />Yes ,] <br />No [-]NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ NA m <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ NA [� <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: — - <br />Permit drawing represents actual location of well <br />YesNo <br />El <br />If `no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes [2 <br />No ❑ <br />Photograph taken and attached to record <br />Yes 4 <br />No ❑ <br />OTHER: <br />Comments: <br />Inspected By: 1 CA -114 � Title: <br />Received By: Date: <br />Cu n-�nn <br />