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x SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br />Telephone: (209) 468-3420 Fax; (209) 468-3433 Web; www.sigov.org/ehd <br />PI IMP IAIGPP:r°Tlr)KI r%Ljl=r°ir i ie -r <br />Address:Perini <br />1� • �`1 �`Ib <br />Parameter/Standard Meets SJC Standards? <br />Ins ctiate: <br />8-O - $ log/.217AW <br />CommentslMeasurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Seal between all pipe columns and casing <br />kYesO <br />WED]NA <br />Sounding tubelair vents sealed properly <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes® <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes © <br />No ❑ <br />NA ❑ <br />JNo ❑ <br />Casing extends at least 1 u above pedestal <br />Yes ® <br />No ❑ <br />NA ❑ <br />No ❑ <br />Free of cracks/contiguous with annular seal <br />Yes ✓❑ <br />No ❑ <br />NA ❑ <br />° <br />Graded to allow drainage away from casing <br />Yes [►� <br />No ❑ <br />NA ❑ <br />No ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes V1 <br />Seal between all pipe columns and casing <br />kYesO <br />WED]NA <br />Sounding tubelair vents sealed properly <br />No cross connections (ex: chemical feeders <br />hooked to distribution systemfag flood irrigation <br />from domestic supply) <br />( <br />Chlorination port available and sealed properly <br />Air gap of at least 6" (same as pipe diameter) <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 V1 <br />- <br />No ❑ NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution systemfag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />- <br />No ❑ NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ NA JVZ <br />MAINTENANCE: <br />We111Pump visible and protected from damage <br />Yes <br />JNo ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No ❑ <br />If `no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes Wq <br />No ❑ <br />Photograph taken and attached to record <br />Yes 10 <br />No ❑ <br />,OTHER: <br />Comments: <br />Inspected By: t\1.,>'V Title: t - S <br />Received By: Date: <br />cu n�nn ��� <br />