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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.slgov.org/ehd 'UMP INSPECTION CHECK LIST Address:.'7163 Ul EDA '2 ' J I VCr -R / ^9 3 L Pet who -39 n- 1 1IpOe :2 Date: Parameter/Standard Meets SJC Standards? CommentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes &' No ❑ NA ❑ J Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least 1" 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 No ❑ NA ❑ Sounding tubelair vents sealed properly Yes ❑ No ❑ NA Q 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 2 No ❑ NA ❑ Adequately installed check valve or BFP device Yes 12 NO ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage IYes © No ❑ NA ❑ Well/Pump free from excessive vegetation IYes [v]' �NoEl NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes LZ No ❑ lf'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: Lk. 1 h q -e L ( Y 41, 4 Inspected By: �So Title: E �� V+Si IJ 4' Received By: Date: (=u n)nn ai�4ronag