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i a t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sinov.om/ehd PUMP INSPF=CM m f`NFr is i 14ZT Address:' PPO T�ermi :� �` 9 is ciionDate; Parameter tandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) - Yes [I] No ❑ NA Ell Casing extends at least 12" above grade Yes [V No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with -annular seal Yes No ❑ NA ❑ Graded to -allow drainage away from casing Yes [0 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 sealedroperly Yes ❑ No ❑ NA [V 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 [a Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA �ImmIN i r-1.4AIVur-: Well/Pump visible and protected from damage Yes I No ❑ NA Well/Pump free from. excessive vegetation Yes g No ❑ NAI MISCELLANEOUS: Permit drawing represents actual location of well Yes No Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes l No OTHER: Comments: Inspected By Received Bv: lf'no' is selected, attach an accurate map to permit rtie�- (� If -i S S I .f f 'V, Date: