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SAMI JOAQ)UMI COUNTY <br /> El',11VIRONNAFENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton A'VeflLle, Stockton, CA 95205-6239 <br /> Tdclpftone:(209) 468-30420 Fax: (209)468-34303 b"lleb:vnwsiggy.orglelld <br /> PURTIP MS3PEGTllOt,,l CHECK L(l'l,'-.;-V <br /> Addr6ss: Permit#.: <br /> Inspection Date. <br /> andards? C ona m e ntsffleas u rem 6nts/ <br /> Parame-terlStandfard affects SJC SL Recommendations <br /> CEIVIENIT PEDESTAL.� <br /> Dimensions Of Surface seal (2'x2'x4j' minimum) Yes NoEl I NIA[I <br /> Casing extends at least 12;' above grade Yes I NoD INAE] I <br /> Casing extends at least V above pedestal Yes No 0 INAE] I <br /> Free of crack/contiguous with annular seadNo F1 I NAE] <br /> cs <br /> Graded to allow drainage away from casing 4jle4sNoE:l INAE] I <br /> S A N Fl"A RY S E A L: <br /> Well is sealed beivveen pLIMP and casing vies No El INA 0❑1 <br /> Seal between all pipe COIL111111S and casing Yes lNoFj I NA[:1 <br /> NA <br /> I : <br /> SOUnding tube/air-vents sealed properly Yes NoEl <br /> Chlorination port available and sealed properly Yes No 0 INAE] I <br /> SAMPLE TAP AND BACKTLOVV PREVENTION. <br /> Non-threaded sample tap between we'11 head and <br /> check valve or within 3' of well head NI/es <br /> Adequately installed check valve or BFP device No [I NA E:l <br /> No cross connections (ex: chemical feeders <br /> hooked to disiribUti011 system/ag flood irrigation <br /> TI-Om domestic supply) YesE] No �j NA El <br /> Air gap of at-least 6:' (same as pipe diameter) IYes ❑ I No ❑ NA I <br /> WAINTEENANCE- <br /> ' <br /> 'Well/Pump visible and protected from darnage Yes No ❑ NA [:] <br /> ;Well/Pump free from excessive vegetation Yes [I N c El NA 11 <br /> FOISCELLANEOUS: <br /> Permit drawing represents actual location of vvell Yes [t NoEl I <br /> -Permit draming Sufficient to locate well in future ',(e s Tho El it'nol is selected,attach 211 accurate map to permit <br /> Photograph taken and attached to record Yes I NO ❑ <br /> OTHER: <br /> C oni ni ents: <br /> \J\ <br /> Inspected By: lTifle: <br /> \j \j <br /> Received Sy: <br /> D&Ee: <br />