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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1668 East Hazeiton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvw.sidov.orgiehd <br />t • f <br />01, <br /> <br />I 44 <br /> <br />- b cc- - <br /> <br />— -- AcrldTsr— <br />\\\ c el ‘i tINN-R Cer'-'C=4 44) . ,k-c-c--\_ -7 ca <br />Permit#: <br />kott-{,h 0.1 ws1 <br />Inspection Date: <br />o1 /4k1t6V-tAtol <br />Parameter/Standard Meets SJC Standards? CO ET1 mentslMeasurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (23 x2ix4" minimum) Yes No NA C <br />Casing extends at least 12" above grade Yes No I I NA q <br />Casing extends at least 1" above pedestal Yes No LI NA <br />Free of cracks/contiguous with annular seal Yes 111 No IINA LI <br />Graded to allow drainage away from casing . Yes CIIII J 11 No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes I No NA <br />Seal between all pipe columns and casing Yes Li No I I NA \i <br />Sounding tube/air vents Sealed properly - Yes I I No NA 4 <br />Chlorination port available and sealed properly Yes No NA -q <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 l I No NA <br />Adequately installed check valve or BFP device Yes H No NA g <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes Li No NA 4 <br />Air gap of at least 6" (same as pipe diameter) Yes No NA j <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes I NO kJ NA I I 410•,It.b.- VW,- i..),_ (RA vtr,-- <br />VVell/Pump free from excessive vegetation Yes No M NA L kiikl,skik---te \--c..a‘,1 yraiu \roe - <br />MISCELLANEOUS: Virekx— \--LAW° vv. SA) . <br />Permit drawing represents actual location of well Yes j No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes .d. No . <br />Photograph taken and attached to record Yes \I No <br />OTHER: <br />Comments: <br />, <br />• <br />\ <br />\\ Inspected By: V, ik,,, 0 1 i ‘ <br />Title: tAV tS-554c . <br />Received By: Date: <br />n b-1.1 fel/A..1C