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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 186.8_East_Hazelton-A-v-en-ue, StQckto_a_, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web. www.sjgov.orq/ehd PUMP INSPC'fC®HCK CIT A dress: gEJACA--M YG PeWffYrN00371 aroma I�rJ 31n Late: ParaameterlStandard Meets SJC Standards? Comments/Measurements! Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes K' No ❑ NA ❑ Casing extends at least 12" above grade Yes [Z No ❑ NA ❑ Casing extends at least V above pedestal Yes Q No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes EV No ❑ NA ❑ Graded to allow drainage away from casing Yes [2 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes - No ❑ NA ❑ Seal between all pipe columns and casing Yes [V No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA [v� Chlorination port available and sealed properly IYes a No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes W No ❑ NA ❑ Adequately installed check valve or BFP device Yes 6/ 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 [�[ MAINTENANCE: Well/Pump visible and protected from damage Yes KZ No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS:— ISCELLANEOUS:.Permit Permitdrawing represents actual location of well . Yes W No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes V No ❑ Photograph taken and attached to record Yes No ❑ OTHER: - _ Comments: 0 b Inspected Sy:�S Title: &y1rfb nih&141 Date: Received By: --1-4c