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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 186.8_Eas.tHazeltonAv-enue,_S-to_GldQD., CA 95205-6232 <br /> Telephone:(209)468-3420 Fax;(209)468-3433 Web:www.sigov.om/ehd <br /> — PUMP INSPEC'TON GRE-GIMS --- -- -- - <br /> Address ��� IV/� P�m�o 0­76 /' i1 1 ro insp )/ <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> R2cOMmendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes a No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes LZ No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes 9 No ❑ NA❑ <br /> Free of crackslcontiguous with annular seal Yes ® No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes0- No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes W No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA Wr ^f <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ No Qj NAE1 <br /> Adequately installed check valve or BFP device Yes JZ No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA[d' <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE; <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA <br /> MISCELLANEOUS: , <br /> Permit drawing represents actual location of well .Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes V No ❑ <br /> OTHER: <br /> Comments: <br /> rJo <br /> Inspected By: Val, �(� Title: & r D"n1,Gh <br /> Received By: Date: <br /> nrnA 1­1 <br />