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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.s►gov.orq/ehd PI IMP IAIGPPr°TlrlA1 P'u>=r v i ic-r Add re s: �� ParameterlStandard �� Ins p on Date: 1 jJ P`a-��38683 © 2 Z Meets SJC Standards? Comments/Measuremen Recommendations CEMENT PEDESTAL: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [� Dimensions of surFace seal (2'xZx4" minimum) Yes Z No ❑ NA ❑ Casing extends at least 12" above grade Yes [A No ❑ NA ❑ Casing extends at least V above pedestal Yes 9 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes In No ❑ NA ❑ Graded to allow drainage away from casing YesjL7] No ❑ NA ❑ SANITARY SEAL: Well/Pump free from excessive vegetation Yes Z No ❑ Well is sealed between pump and casing Yes No [I NA ❑ Seal between all pipe columns and casing Yes © No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ® No E] NA ❑ Chlorination port available and sealed properly Yes EDNo EE] Eq JrilYlr j-" i 1-+r- r►iYv caH%,nrL.UVV I -Mr -V I=N I IUIV: ' Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [� Adequately installed check valve or BFP device IYes Z No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic su ply) Yes ❑ No ❑ NA Air gap of at [east 6" (same as pipe diameter) Yes ❑ No ❑ NA 11 MAINTENANCE: Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Z No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes W 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future ]Yes ffEl Photograph taken and attached to record Yes [✓] OTHER: Comments: e Received F::u nonn Title: E_ 4 Date: