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SAN jOAGUINJ COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 fax: (209) 468-3433 Web:wwVv.sigov.orq/ehd <br /> _ PUMP RMISPEC T[(:N CF ECK LIST _ <br /> Address: 3 4 ^ 1 O S KOS� � , C Perm 0 D 3 4 � Inst�1 /aie: <br /> �( �l <br /> Parameter/Standard Meets SJC Standards? Comments1hrleasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 2 No ❑ NA❑ j <br /> Casing extends at least 12" above grade Yes No ❑ INAD <br /> Casing extends at least 1" above pedestal (Yes [2 No ❑ INA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ I' <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pwrlp and casing Yes [0 No ❑ NA ❑ <br /> Seal between all pipe columns and casing IYes Q No ❑ NA ❑ I <br /> (Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [✓� <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ <br /> SAMPLE TAP AND BACKFLOV11 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 LZ No ❑ NA ❑ j <br /> IN cross connections (ex: chemical feeders <br /> Ihooked to distribution system/ag flood irrigation <br /> lirom domestic supply) Yes ❑ No ❑ NA 0 <br /> 'Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [� <br /> MAINITENANCE: <br /> IVtlell/Pump visible and protected from damage Yes V No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes D No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ 1 'no'is selected, a«ach an accurate map to permit <br /> (Photograph taken and attached to record Yes No ❑ <br /> OTHER: _ 1 <br /> Comments: <br /> ! �A n s Pew �� Com, so-�•, h P_ we /ls� re P, I <br /> 0" 1 <br /> I <br /> a <br /> a <br /> Inspected By: a S� (Title: E N A rji' k <br /> I Received By: I Date: <br /> Gu norm QIQaron�r <br />