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r� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8_East_Hazelton.Aveaue,flcto_t�. CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.orq/ehd PUMP INSPECT I� Llai Address: r (� ��G L C PC'V i '� i��% ��I Permi 03 7i-3 Insp cfion ate: 1 3 . . Parameter/standard Meets 5JC Standards? Comments/Measurements] Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑1/j No ❑ NA ❑ NA Casing extends at least 12" above grade Yes V No ❑ NA ❑ No ❑ Casing extends at least V above pedestal Yes 10 No ❑ NA ❑ Photograph taken and attached to record Free of crackslcontiguous 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 No ❑- NA ❑ Sounding tubelair vents sealed properly - Yes ❑ No ❑ NA Wf Chlorination port available and sealed properly 1 Yes &T No ❑ NA ❑ SAMPLE TAP AND 13ACKFLOW PREVENTION: Non -threaded sample flap between well head and check valve or within 3' of wellhead Yes ❑ No1V NA ❑ Adequately installed check valve or BFP device Yes Y No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" same as pipe diameter) YesE] No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ VVelllPump free from excessive vegetation Yes V INo ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well Yes bZ No ❑ lf'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 2 No ❑ OTHER: Comments: > C S � nspecfed By: ( Title: r-vnmz A deceived Bv: Date: n 1n1 -4G