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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.sigov.orq/ehd PUMP WSPEC T ION CHECK LIST Address: Permit#: I�pen Dafe: 31 w . LST oP� mE� sK�ao .7�, / O � I c ��y i ParameterlStandard Meets SJC Standards? CommentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal YesW 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 tube/air vents sealed properly Yes ❑ No ❑ NA Qa' Chlorination port available and sealed properly Yes EV No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes W No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ lNo ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes © No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ® No ❑ INA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes © No ❑ Permit drawing sufficient to locate well in future Yes No ❑ 1f'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes [V No ❑ OTHER: Cowi�ments: i Inspected By: S Title: Received By: Date: Mu nr)nn rzi�di�n4r