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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 fax: (209)468-3433 Web:www.sjgov.orq/ehd _ GRUMP INSPECTION CHECK LIST Address: Permi Ins ction Date: •FI � tjTEcA w F oo3-7-»s ,p / ParameterlStandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [9 No ❑ NA❑ Casing extends at least 12" above grade Yes [a No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [2 No ❑ NA ❑ Graded to allow drainage away from casing IYes I 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 [ ' Chlorination port available and sealed properly Yes © 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 9 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA�-ej Air gap of at least 6" (same as pipe diameter) Yes INo ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No E] NA❑ Well/Pump free from excessive vegetation Yes [ No El NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ Permit drawing sufficient to locate well in future Yes 0 No ❑ If'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Q,k Title: H A V,j Received By: jDate: Mu n�nn Rr�ai�nar_