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SAN-..iOAQUINI COUNITY <br /> ENVIRONIMIENTAL HEALTH DEPARTMENT <br /> 1868 East Flazelt-On Avenue, Stockton, CA 95205-6232 <br /> Tele,phone: (209) 468-3420 Fax: (209)468-3433 VLfeb:.w\k�li.si_aov.orq/elid <br /> f.dFlUNAP RMSPECT[014 GF-1ECK UIST <br /> di-C <br /> Insp <br /> tion Dpt <br /> El—2-17-F, <br /> I cA 1-11VD YvO 38 /21 !`, <br /> PararneferlStandard Nrleets SJC Standards? Conune-- 1eaSLTr Ments] <br /> Recommendations <br /> CEMR.Tf PEDESTAL: <br /> Dimensions of surFace seal (2'x2'x4" minimum) Yes EVI jNoM NA Ej <br /> Casing extends at least 12"' above grade Yes R I—No—EjTNA r-1 <br /> i Casing extends at least I" above pedestal Yea R NDFJ NAD <br /> Free of cracksk-ontiguousvvith annular seal Yes © No El NAD <br /> Graded to allow drainage away from casing YesNo ❑ INA ❑ <br /> SANITARY SEAL: II <br /> Well is sealed between JDUMp and casing Yes NA F-1 <br /> `Seal between all pipe columns and casing Yes E,2 NoEJINA O I <br /> 'Sounding tribe/air vents sealed properly QjYes I NoF INA IV I <br /> Chlorination port available and sealed properly Yes VIN o�01 NA El <br /> SAIMPLE TAP AND BACKIFLOVil PREVENT[ON: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes � No [I NA El <br /> fl-Wequately installed check valve or BFP device Yes -V No El INA El <br /> No cross connections (ex: chemical feeders <br /> !hooked to distribution system/ag flood irrigation <br /> I <br /> ifi-om domestic supply) Yes El NoF1 NA [V <br /> Air gap of at least T (same as pipe diameter) I YesEl No ffl NA L-q <br /> IMAINTENANGE: <br /> ii:A[Vell/Purnp visible and protected from damage Yes S2 I NoEl INAF-1 III <br /> jVVell/Purnp free from excessive vegetation Yes [� I No El NA Ej- I <br /> 1111111SCELLANEOU-S. yy <br /> Permit drawing represents actual location of well IYes [j2 No El iI <br /> -Permit drawing sufflicient"Lo locate well in future IYes No 7 11'no2 is selected, atach an accurate map to pc-!T'Pi-E <br /> ,Photograph taken and attached to record IYes WX No 0 <br /> 10 TH ILE R: <br /> o rn nn e nts <br /> L-A <br /> culy-4 <br /> �' <br /> ti it <br /> Inspected By: Y" <br /> T 1 t I e: <br /> i�,IReceived T Da-LC-: <br />