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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186.8_East-Hazelton-Av-enue, Sio-c, CA 95205-6232 _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd PUMP INSP�C�i FO -GFfEWCFC-LIs I ' Address: r- Permi Insp cti ate: ;$�6 S• jAGI�'J��J �� SIpCjCI�� iZ oo-1 Sq Parameter/Standard Meets 5JC Standards? CommentslMeasurements! Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes M No ❑ NA ❑ NA ❑ Casing extends at least 12" above grade Yes M No ❑ NA ❑ NA ❑ Casing extends at least V above pedestal Yes M No ❑ NA ❑ NA Free of cracks/contiguous with annular seal Yes K No ❑ NA ❑ NAM Graded to allow drainage away from casing Yes P6 No ❑ NA ❑ No ❑ SANITARY SEAL: Well is sealed between. pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes V No ❑ NA ❑ Sounding tubelair vents sealed properly - Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes ❑ No ❑ NAM SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of wellhead Yes M' No ❑ NA ❑ Adequately installed check valve or BFP device Yes L4 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA M Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 9 MAINTENANCE: Well/Pump visible and protected from damage Yes F/I . No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [✓] No ❑ NA D MISCELLANEOUS: , Permit drawing represents actual location of well . Yes No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Y2S No ❑ �Photoaraph taken and attached to record Yes 0 No ❑ OTHER: Comments: Ins Received Title: &V1 r'b nAU4 Date: Pa(- A.Si f -