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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.868_East-Hazelton-Avenue, atocktan, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PUMP N PECT(OTJi-CHEC{_LIST Address: l/�•S1EST� Ct TR/4G Permit#: P,ov7il�I Inspection Date: to IQ 1/i Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes Qj No ❑ NA ❑ Casing extends at least 12" above grade Yes W 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 M No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes V- No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA [i/ Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes FA No ❑ NA ❑ Adequately installed check valve or BFP device Yes 0 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 10 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA EZ MAINTENANCE: Well/Pump visible and protected from damage Yes EMNo ❑ NA ❑ Well/Pump free from excessive vegetation I Yes 0A No ❑ NA [� MISCELLANEOUS: Permit drawing represents actual location of well . Yes LZ 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 [V No ❑ OTHER - Comments: kA.i, ;f e, Inspected By: Title: nmA44ttQ4(1{. Received By: Date: AInA In 4c