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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd Td7Z—s—: -------"- _ 1 k \ 5D q c'c'e 9-A) Ko • C-C-INC.>/k 1 Lt, R e-1--1 Permit#: Tinpion 5(„ no-1 -- Date: o‘kl \c‘i A Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x21x4" minimum) Yes 1-1 No I I NA r Casing extends at least 12" above grade Yes No NA KI Casing extends at least 1" above pedestal Yes E No LI NA 14 Free of cracks/contiguous with annular seal Yes 1-1 No NA Ini Graded to allow drainage away from casing Yes No I I NA IV SANITARY 'SEAL: Well is sealed between pump and casing Yes JI No Li NA I Seal between all pipe columns and casing Yes n No R NA r1-3.)ktyico,„Th-c- t7 (--, 144 L.- t9 IV i Sounding tube/air vents Sealed properly - Yes F No I NA q Chlorination port available and sealed properly Yes n No NA 14 SAMPLE TAP AND BACKFLOW PREVENTION Non-threaded sample tap between well head and check valve or within 3' of well head Yes Li No I NA 4 Adequately installed check valve or BFP device Yes No ri NA L No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes n No \I NA I I Air gap of at least 6" (same as pipe diameter) Yes n No NA n MAINTENANCE: Well/Pump visible and protected from damage Yes 4 No NA Li Well/Pump free from excessive vegetation Yes No ri NA . MISCELLANEOUS: Permit drawing represents actual location of well Yes No ri It no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No n Photograph taken and attached to record Yes No n OTHER: Comments: • ‘ Inspected By: V \i1 !il I Title: Received By: Date: