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SAN jO/ QLJ1N C.,OUNITY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1365 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fa;;. (209) 468-3433 Vileh;vv�1rw.sicov.ord/e hd <br /> Address- Permi' �,'ni�s <br /> iHAZLE1aOU T Frc,4Lo � 37S a t <br /> PararnecerlStandard Meets SJC Standards? <br /> Commentsfhheasurements! 1 <br /> _ d <br /> Recommenations <br /> 10E[�iEl i-[' r-'ED1=ST��.�.F I <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes [T/ hyo ❑ INA ❑ <br /> Casing extends at least 12" above grade Yes V INo ❑ INA ❑ { <br /> Casing extends at least 1" above pedestal Yes 2 No ❑ NA ❑ <br /> ;Free of cracks/contiguous with annular seal Yes ❑✓ No ❑ I NA❑ <br /> Graded to allow drainage away from casing IYes 9 No ❑ NA ❑ <br /> 1 <br /> SAt1[TARY SEAL: l <br /> i <br /> Well is sealed between pump and casing Yes V INo ❑ INA ❑ 1 <br /> Seal between all pipe columns and casing Yes Q No ❑ NA ❑ # <br /> �SOLlnding tube/air vents sealed properly Yes ❑ No ❑ INA [� <br /> Chlorination port available and sealed properly Yes V I No ❑ I NA ❑ i <br /> SAMPLE TAI"' AND SACKFLOIN P1?:EVENTION: it <br /> r <br /> ;Non-threaded sample tap between well head and <br /> icI Teck valve or within 3' of well head Yes 9 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes M No ❑ NA ❑ <br /> 1No cross connections (ex: chemical feeders <br /> Ihooked to distribution system/ag flood irrigation <br /> ifrom domestic supply) Yes ❑ No ❑ NA 2 i <br /> ;Air gap of at least 6" (same as pipe diameter) Yes ❑ INo ❑ INA Q <br /> 1MAINTENANCE: <br /> i <br /> ,VVell/Pump visible and protected from damage IYes C✓1 I.No ❑ INA ❑ <br /> !Well/Purnp free from excessive vegetation Yes �] No ❑ INA ❑ <br /> ,(MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes INo ❑ � <br /> i <br /> (Permit drawing sufficient to locate well in future Yes 0 No ❑ 11'no'is selected, at-iach an accurate map to permit <br /> IPhotograph taken and attached to record Yes [�INo ❑ <br /> OTHER: — -- <br /> Comments. <br /> op �, �S ��h, �-� i h s <br /> i' <br /> i <br /> k l <br /> I <br /> ,Inspected By: Gtc. ,517 — _-----___---- —— Title: <br /> 14 - ASl fu ? *r <br /> t <br /> V Received By; --- Date: i1 <br /> r_u norm <br />