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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; vwvw.sigov.org/ehd PI IUD iKtcp1=r-rinnr r%=r•lr 1 10r Address: , f J M I G K/_ Q v n �( I v G �"Y Parameter/Standard Meets SJC Standards? w Inspction pate: Perm311 w Moo 3� 12,10 1 r Comments Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ No ❑ Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ No ❑ Casing extends at least V above pedestal Yes ❑ No ❑ NA ❑ Yes ❑ Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA ❑ Yes ❑ Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ MISCELLANEOUS: SANITARY SEAL: Well is sealed between pump and casing Yes ❑tN o ❑FNA ❑ Yes ❑ Seal between all pipe columns and casing Yes ❑o ❑ ❑ OTHER: 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 flap between well head and check valve or within 3' of well head 1YesE1 lNo ❑ INAE] Adequately installed check valve or BFP device I Yes ❑ No ❑ NA ❑ 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 ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes ❑ No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ❑ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ❑ No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ❑ No ❑ Photograph taken and attached to record Yes ❑ No ❑ OTHER: Comments: Yz MN'J4 w{,.e-. Ceti,Se�� Inspected By: Received Bv: =0 n )nn Title: r.� S I Date: