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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1-86.8_East_Hazelton_Aicenue,_atocktooD., CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd -- - - PUMPINSPfvCTfON �FI�CKLIST Address: r,Permi C 4Gf'f Q 0 o f *W C)0 1 Inspection Date: 1/ c i -i Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes a No ❑ NA ❑ Casing extends at least 12" above grade Yes &Z No ❑ NA ❑ Casing extends at least T' above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous 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 W No ❑ NA ❑ Sounding tube/air vents sealed properly Yes EV No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No0,NAjV SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA W1 Adequately installed check valve or BFP device Yes kA No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA CV Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ 1 NA MAINTENANCE: Well/Pump visible and protected from damage Yes 9 No ❑ I NA ❑ Well/Pump free from excessive vegetation Yes W1 jNoE1 INA El I MISCELLANEOUS: Permit drawing represents actual location of well . Yes [J]' 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 No ❑ OTHER: Comments: Inspected By: � 0-4 5o Title: Received By: Date: h