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l <br /> !^ J <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 186.8-East-HazeltonAvelaue,-SioQktm, CA 95205-6232 _ <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> PUMPINSPE-GTFON-GflBOKUS <br /> Address: Perm! Insp ction at <br /> '1 r( ' o C--Q L IJ �-u i D ©3 q2 l( �o,� j <br /> Parameter/Standard =MeetsSJC Standards? <br /> Comm entslMeasurem encs/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes g 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 crackslcontiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes[n 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 No ❑ NA❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA[1/1 <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA Q0 <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ No ❑ NA <br /> Adequately installed check valve or BFP device Yes to No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[V <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [1 No ❑ NA Ej <br /> MISCELLANEOUS, . <br /> Permit drawing represents actual location of well .Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes 54 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> i <br /> Inspected By:L `lo Title: 1'Oh/rIIM Q 1 }�-e�►/f NJJt` <br /> Received By: Date: <br /> n fnA fnnAC <br />