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SA.N..'i0AQ1U1H COUNTY <br /> EI`dVlRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelt-On Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)�4[6{8�-1�3d4112L0n Fax..¢(20gp9gO) 4658-13433 V1l6h:v wvv.sjpov.org/ehd <br /> �,Y1'[W 41:Y?EJ/h�1�.�..4•�k4.?1�1 F..YL r.E-"CK i—IS II <br /> .Address: I'er In V D <br /> q�D 1 gy m �3 C-4 'V&03S aa, I) C! <br /> —r <br /> 1'aramercr/�•andard 'Meets ilJC Standards? Comments[ easurements/ y <br /> �iI <br /> I Recosnrnenda�ions <br /> CE&rjEI'JT PEDES T AG_ <br /> (Dimensions Of surface seal (2'x2'x4" minimum) Yes Q talo 17 NA ❑ <br /> Casing extends at least 12" above grade Yes [ No [-] NA ❑ ! <br /> 'Casing extends at least 1" above pedestal Yes Q No [:1 NA [j <br /> Free of cracks/cont>guous v�/ith annular seal Yes [� I�lo ElNA ❑ _ <br /> jGraded to allow drainage away from casing IYes W1Nc 0N ElI I <br /> SANITARY SEAL: i+ <br /> Pell is sealed between pump and casing Yes No ❑ NA ❑ <br /> I <br /> Seal between all pipe columns and casing IYes NA ❑ i <br /> ;Sounding tubefail" vents sealed properly Yes ❑ No ❑ NA Q I I <br /> jChlorination port available and sealed properly Yes [/ JNo ❑ INA ❑ II <br /> ISArLAPLE TAP AND BACK]FLOA1 PREVEN110N. �+ <br /> �I <br /> (Non-threaded sample tap between well head and ! <br /> (check valve or within 3' of well head Yes ,/l No ❑ NA ❑ �I <br /> !Adequately installed check valve or BFP device Yes [Z No ❑ NA❑ <br /> !No cross connections (ex: chemical feeders j <br /> (hooked to distribution system/ag flood irrigation <br /> ;from domestic supply) Yes ❑ No ❑ NA 1F Ii <br /> j Air gap of at least 6" (same as pipe diameter) 1'es El INo ❑ (NA Q <br /> MAINTEI ANNE: <br /> Well/Pump visible and protected from damage Yes L-q No ❑ NA❑ I� <br /> Well/Pump free from excessive vegetation Yes 0 No ❑ NA❑ <br /> MISCELLANEOUS I• <br /> Ij <br /> (Permit drawing represents actual location of well IYes 5� No ❑ t <br /> Permit drawing sufficient to locate well In future IYes 0 INo ❑ 11'no'is selected,a«acn an accurate map to permit �{ <br /> (Photograph taken and attached to record `r'es F.A No ❑ <br /> 1 G T H LE <br /> �+wol invents: <br /> if-}< <br /> h 5 { <br /> f I! <br /> I� I; <br /> Inspected By: �► I S� -- — — ITitle: <br /> II <br /> y <br /> Received By: Date: <br /> r_1_ „onn <br /> R/Q-1i7i1iF <br />