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J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - --- 1-86.8-East_Hazelton_Avenue,_atOcktQn, CA 95205-6232 _ Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.oM1ehd PUMP INSPECTFOWGHE-CK-LIST -- -- Address: 14 fn T �c Perm • wi ov3686z In, tion ate: >ar; Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [Z No ❑ NA ❑ Casing extends at least 12" above grade Yes W No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [o No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes ij INo ❑ 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 No ❑ NA ❑ SAMPLE TAP AND BACKIFLOW PREVENTION: Non -threaded sample flap 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 FU Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [m MAINTENANCE: Well/Pump visible and protected from damage Yes V No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well . Yes gl No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Pf No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: &VI N nnU h a IJO Received By: Date: -A In 4C