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SAN JOAQUIN'COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orgleid <br /> Addiress: Permit#: Inspection Date: <br /> fl u h ISO�N <br /> ParametedStandard Meets SJG Standards? Coin nzentslMeasttremerits/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ I No ❑ NA❑ <br /> at least 12" above rade Yes No NA <br /> Casing extendst g ❑ ❑ ❑ _ <br /> Casing extends at least V 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 purnp and casing Yes ❑ INo ❑ INA❑ <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 `les ❑ No ❑ NA❑ <br /> SAMPLE TAP AND DACFa1=LOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ No ❑ NA❑ i <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 ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ❑ No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes ❑ No ❑ NA❑ <br /> MISCr LLANEOUS: <br /> Permit drawing represents actual location of well IYes ❑ 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 IYes ❑ No ❑ <br /> OTHER: <br /> Comments: - -- <br /> A\\ <br /> f. <br /> Inspected By: -- _ - -- Title: <br /> Received By: Date: <br /> ARIA iIPAG <br />