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l <br /> T J <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1.86.8_East_HazeltonAv�nuQ,�S-tQ-ckto ., CA 95205-6232 _ <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orq/ehd <br /> P[!VIP INSPECTON GRI;GKtrS — <br /> Address: Permi Inspeotion ate: <br /> l SK�J J C L,Tb w ao 3 6 9,76 r r /off <br /> Parameter/Standard Meets SJC Standards? CommentslMeasurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [+1x No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes ® No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes ®' No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between.pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes h2 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA KZ <br /> Chlorination port available and sealed properly Yes No ❑ 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 Yes No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yesmf `N o ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 11 No ❑ NAE1 <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well .Yes JZ No ❑ <br /> Permit drawing sufficient to locate well in future Yes hZ No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: VOWA tj;'b Title: Ae,Itk AJS <br /> Received By: Date: <br />