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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1.86.8-East_HazeltonAvenue,_StucktQ, CA 95206-6232 _ <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> -- -_ - PUMPISN -PECT[G ZHE-GKIIST - -- <br /> Address: I" , ^ S V' r' � / Permit O �� O Inspection Dale: <br /> Parameter/Standard IC.� UMeCet's SJCC Standards? Comments/Measurementslll <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes F2 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes V No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NAM <br /> Chlorination port available and sealed properly IYes W No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and ►J sn,"y <br /> check valve or within 3' of well head Yes ❑ No 9 NA❑ <br /> Adequately installed check valve or BFP device Yes W No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> I <br /> rom domestic supply) Yes ❑ No ❑ NA R <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ lNo ❑ INA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 9 No ❑ NA❑ <br /> Mll/Pump free from excessive vegetation Yes kX INo ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well -.Yes W No ❑ <br /> Permit drawing sufficient to locate well in future Yes ®' No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes R9f No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: <br /> Received By Date: <br /> n lnAlnnAc <br />