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P f , Y e 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.orq/ehd PI IMP INSPFCTInN r.WF:r v I ICT Address ^ �� W ) Perms t •- Ins e "on D te: 1. � I ' d a38s33 0 ParameterlStandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) I Yes [0 1 No Ell NA ❑ Well/Pump free from excessive vegetation Casing extends at least 12" above grade Yes [Jf I No ❑ NA ❑ MISCELLANEOUS: Casing extends at least 1" above pedestal Yes No ❑ NA ❑ _ Free of cracks/contiguous with annular seal Yes [j No ❑ NA ❑ PA j Cr (',1. Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes []/ No ❑ NA ❑ Seal between all pipe columns and casing Yes EA No ❑ INA ❑ Sounding tube/air vents sealed properly Yes [Al LNo ❑ INA ❑ Chlorination port available and sealed properly Yes [2 No ❑ INAD SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [SI No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ �No ❑ NA Q - Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 1111A1N 1 tNANL;t: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 2 No ❑ lf'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes U No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comment Inspected By: Title: As3 l Received By: Date: cu AOnn