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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8_East_Hazelton_Aviceriue,_Stockto-o., CA 95205-6232 _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PUMP INSPECTFOWGIFFECKLIST - - Add�s:Permit W -5d � -b (T'TP- ��(- : WICbo3-7410 Inspection ate: 1 10�a7 (11- Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [:d No ❑ NA ❑ Casing extends at least 12" above grade Yes W No ❑ NA ❑ Casing extends at least V above pedestal Yes [A No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes V No ❑ NA ❑ Mi hr G-�.Go Graded to allow drainage away from casing Yes V No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes F No ❑ NA ❑ Seal between all pipe columns and casing Yes [0 No ❑ NA ❑ Sounding tube/air vents healed properly - Yes ❑ No ❑ NA Y Chlorination port available and sealed properly Yes W No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes V No ❑ NA ❑ Adequately installed check valve or BFP device Yes P/ No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA©' Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA V MAINTENANCE: Well/Pump visible and protected from damage Yes EO ,No ❑ NA ❑ Well/Pump free from excessive vegetation Yes VT No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well . Yes U No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes FV No ❑ Photograph taken and attached to record Yes E ( No ❑ OTHER: Comments: Inspected By: (aA Title: 6,1 Received By: Date: —11