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SAN JOAQUIN COUNTY <br />` ENVIRONMENTAL HEALTH DEPARTMENT <br />1868_East_Liazelton&v-ent re,-StQakto 3-, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.orq/ehd <br />PUMP PE-CTCON-GFl­ECK1IST <br />oCC;i/,� <br />Parameter/Standard <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum Yes <br />Casing extends at least 12" above grade Yes <br />Casing extends at least 1" above pedestal Yes <br />Free of cracks/contiguous with annular seal Yes <br />Graded to allow drainage away from casing Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes <br />Seal between all pipe columns and casing Yes <br />Sounding tube/air vents sealed properly - Yes <br />Chlorination port available and sealed properly Yes <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head Yes <br />Adequately installed check valve or BFP device Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes <br />Air gap of at least 6" (same as pipe diameter) Yes <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes <br />Well/Pump free from excessive vegetation Yes <br />MISCELLANEOUS: . <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photoarai)h taken and attached to record <br />Permit.#: /Insp cti <br />L/vro��3G��S ton <br />Meets BJC Standards? Comments/Measurements/ <br />Recommendations <br />OTHER: <br />Comments: <br />No <br />No <br />No <br />No <br />No <br />m <br />m <br />m <br />No U NA LJ <br />No E:1 NA El <br />No ❑ NA [jj <br />No ❑ NA ❑ <br />No ❑ NA ❑ <br />No El NA El <br />■ <br />m■1 <br />' M I! <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />If'no' is selected, attach an accurate map to permit <br />Inspected By: Y GLAx I /V U Title: t2n III rD nrKxAT-,Q1 U�- l l rl J ; <br />Received By: Date: <br />