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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgiehd <br />",.. <br />7.-cidress:.--- —1/4,---7 ------ <br />\ (7 WA C) . CALA-A)'-‘ 'c'\i‘ti - U.c\ASIA <br />(CW <br />Permit#: <br />V') q tOb "71% <br />Inspection Date: <br />Wkl Ck 1 t C1( i <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Si No NA <br />Casing extends at least 12" above grade Yes No n NA <br />Casing extends at least 1" above pedestal Yes L1 No NA I I <br />Free of cracks/contiguous with annular seal Yes No Li NA ri <br />Graded to allow drainage away from casing Yes No I I NA n • <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes — No j NA I I <br />Seal between all pipe columns and casing Yes No NA I I <br />Sounding tube/air vents sealed properly - Yes n No i- NA n <br />Chlorination port available and sealed properly Yes No Lii NA TI <br />SAMPLE TAP AND BACKFLOW PREVENTION <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes I I No I I NA <br />Adequately installed check valve or BFP device Yes n No 1 I NA 1-1 <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LI NA n <br />Air gap of at least 6" (same as pipe diameter) Yes n No n NA <br />MAINTENANCE: <br />1 <br />1 <br />Well/Pump visible and protected from damage Yes I I NO rQ' NA1 I . <br />Well/Pump free from excessive vegetation Yes K..) No 1--- NA TI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IV( No 11 <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [Xj) No LI <br />Photograph taken and attached to record Yee V No LI <br />OTHER: . <br />Comments: <br />1 . eA)k)k-stAz V-1 <br />( ckits-AA.,u.) <br />cs-s--- t-v•\-,--- wt,--\--\_, ,',)v<--> ,,u,,i._- Q-ir_AV‹A) -1\- <br />9 Nst= kk) \ tiQ T -\•-)\f'c-- - N bW S ? V) <br />coc-.A\A— w (IA-xi ic-- ,.,-,,,,k,, z.1.1,11 /4., T.\ LA_b-i.._ <br />Inspected By: Title: IAA Vt c"nsi • <br />Received By: Date: <br />n/014 f•1/1,1r