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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8_East_Hazelton_Avenue, St_2ckto., CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd PUMP f(-SPECTFON-GFIEICKtIST AddressPermit 6 0 E-A) I i c LA 1-) pc)o 3-7 3-5, Inspection Date: 10127// Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes V No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes R1 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes U No ❑ NA ❑ Seal between all pipe columns and casing Yes 2 No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA [0 Chlorination port available and sealed properly Yes Qi" No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes JZ No ❑ NA ❑ Adequately installed check valve or BFP device Yes o No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 0 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA i/ WMAINTENANCE: ell/Pum visible and protected from damage IYes V [No ❑ NA ❑ Well/Pump free from excessive vegetation IYes V I No ❑ INA [] MISCELLANEOUS: Permit drawing represents actual location of well . Yes 9 No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [9 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: -- Comments Inspected By: CL+1 [ Title: &yl rOhM1A++a) ►T'e off Received By: Date: �—, 4