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F 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 INSP1=rTInfJ (`14I=r'_K 11QT Address: IISQAl�• VALP Co �� i'6Z� c Permi W 00368�7� Inspection Date: ParameterlStandard Meets SJC Standards? Comments/Measurements Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [O No ❑ NA ❑ Casing extends at least 12"_ above grade Yes 2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ 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 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes 9 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 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 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: vVell/Fump visible and protected from damage I Yes Well/Pump free from excessive vegetation 1yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: No Lj INA No 1-1 INA Yes No ❑ Yes Z No ❑ If'no' is selected, attach an accurate map to perp ii Yes &t No ❑ Inspected By: 11,Title: Received By: Date: