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4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PI IMP IIUCP1=rTIr1KI P9uC:rLr 11c'r Address: jZq • �u�� and heck valve or within 3' of well hYes [Adequately on -threaded sample tap betweAdiameter) No ❑ Permit#• W P00.91 r Insp ction Date: �a Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: ❑ No ❑ NA Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA EJ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No [E:] NA' El Graded to allow drainage away from casing Yes No ❑NA ❑ SANITARY SEAL: Permit drawing sufficient to locate well in future Yes No ❑ Well is sealed between pump and casing Yes . No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes No ❑ NA ❑ AIVIVLt I,AF AND 13ACKFLOW PREVENTION: and heck valve or within 3' of well hYes [Adequately on -threaded sample tap betweAdiameter) No ❑ NA ❑ installed check valveice Yes �' No ❑ NA ❑ No cross connections (ex: chemi hooked to distribution system/ag ion from domestic supply) ,Yes ❑ No ❑ NA Air gapof at least 6" (same as pi Yes ❑ No ❑ NA [17� MAINTENANCE: - Well/Pump visible and protected from damage Yes 0 No [:1 Well/Pump free from excessive vegetation Yes No F] NA HE] MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: / Inspected Received Date: