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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> T efephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.orglehd <br /> Address: —m�T Permit#: T�� <br /> pection Date: <br /> \3A °c Z 1 20 kl\ <br /> Parameter/Standard Meefs Cor ism encs/Measurements/SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minirnum) Yes ❑ 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 lYes ❑ lNo ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ❑ No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA❑ <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 wellhead 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 /> frorn domestic supply) Yes ❑ No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected frorn damage Yes ❑ No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes ❑ No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes ❑ No ❑ <br /> Permit drawing sufficient to locate well in future Yes ❑ 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 /> i <br /> I <br /> Inspected By: N WWI Title: <br /> Received By: Date: <br />