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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8-East-HazeltonlAvenuLe�StQckto-, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PUMP ON CHECK ST Address:, I 44- /n,` LiIJb &944 - Vii` Permi WW003iS I ate: Insp ctioa Date- a7 9/1 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum Yes [� No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes P No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes M No ❑ �NAFI NA ❑ Graded to allow drainage away from casing Yes [� No ❑ SANITARY SEAL: Well is sealed between pump and casing Yes EU No ❑ NA ❑ Seal between all pipe columns and casing Yes Q' No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA V/ Chlorination port available and sealed properly Yes I No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes No ❑ NA ❑ Adequately installed check valve or BFP device Yes 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 [0 MAINTENANCE: Well/Pump visible and protected from damage Yes 19 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA [j MISCELLANEOUS: Permit drawing represents actual location of well . Yes ® 1NoE1 If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes U No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: &V r'pA Received By: Date: