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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -- 1.868-East-Hazelton_Av_enue,_Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd -- - PUMP INSRCTI016F_GflE_GK_LIST_ Address: 7 N, cox 12-J L1100Cd Permit. WPO0 3_� TH e tlo InspDate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Ye No ❑ NA ❑ Casing extends at least 12" above grade Yesa No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes kZ No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes V No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA VI SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Ye No ❑ INA Tf Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) I Yes ❑ No ❑ NA Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NAZI MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ INA Ej MISCELLANEOUS: _ Permit drawing represents actual location of well Yes No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: - - - - Comments: / Inspected By: W"� S Title: t'T' I'1 °f is Received By: Date: