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' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1.86.8_East_Hazelton-Av�nue,_atocktm, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />- — PI IMP I C-TF0- -GHE-CKCLFST — - - - - <br />mlazpflf <br />PerIT 7 O <br />Ini pecnate: <br />, <br />O 4 <br />03207/4, <br />_Address: <br />Parameter/Standard <br />Meets SJC Standards? <br />Comm ents/MeaSUrem ents/ <br />Recommendations <br />CEMENT PEDESTAL: _ <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes M <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Casing extends at least 1" above pedestal <br />Yes LA <br />Yes JW <br />No ❑ <br />No W1 <br />NA ❑ <br />NA ❑ <br />c-9 r h iesi f�` � q <br />Free of cracks/contiguous with annular seal <br />Yes 0 <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [Z <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes W <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes 10 <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly - <br />Yes ❑ <br />No ❑ <br />NA <br />Chlorination port available and sealed properly <br />Yes 0 <br />No ❑ <br />NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes ❑ <br />No V <br />NA ❑ <br />„/v S--^ <br />Adequately installed check valve or BFP device <br />Yes hZ <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA to <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />lNo ❑ <br />NA [j <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes Q <br />No ❑ <br />NA ❑ <br />_ <br />Well/Pump free from excessive vegetation <br />IYes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes ✓Q <br />No ❑ <br />If 'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes © <br />No ❑ <br />Photograph taken and attached to record <br />Yes © <br />No ❑ <br />OTHER: <br />Comments: <br />�CSis (A51 <br />P <br />Inspected By: <br />Title: H- Anis <br />Received By: <br />Date: <br />n -A MnA C <br />