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F ' A 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.siAov.orq/ehd <br />PI IMP IAIC131=r°TInK1 Mjl=r�w I Ie•r <br />Address, <br />W Chi ► b OF ry /j <br />V <br />pS roC)7, qac erm <br />Inspection Date: <br />Parameter/Standard <br />Meets SJC Standards? <br />I Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes Q <br />No ❑ <br />NA ❑ <br />Casing extends at least 12". above grade <br />Yes Q <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes © <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [J <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes © <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA <br />Chlorination port available and sealed properly <br />Yes g <br />No ❑ <br />NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />A E <br />N' S <br />Adequately installed check valve or BFP device <br />Yes <br />4oNA <br />❑ <br />C-arm K4 - 1oc,,ft_; <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA [� <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />MAIN I tNAN6t: <br />Well/Pump visible and protected from damageYes No ❑ NA ❑ <br />Well/Pump free from excessive vegetation dYes4Z <br />No ❑ INA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes V No [ <br />Permit drawing sufficient to locate well in future Yes No [ <br />Photograph taken and attached to record Yes No [ <br />OTHER: <br />Comments:\ C n <br />0..ww,l'r <br />If 'no' is selected, attach an accurate map to permit <br />vC_�/ g P P oLwtu <br />,i ispectea my: % IJIM v J Title: Ljpq\/t rU 0 rrjAf-,, i l S / IiLA <br />Received By: Date: <br />