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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT -- --- 1-86.8_East_Hazelton_Ave.nue,_StQcktQn., CA 95205-6232 _ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd PUMP INSPECTFClWGflECKLIS — -- _ Address*o�r A N tj R S� �sCA � � 1 Per lit In)3 do Date: 1111 b 2 E L N IS�t -T� , 8 0 Parameter/Standard Meets SJC Standards? Comments/Measurements/ 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 Yes 0 No ❑ NA❑ Free of cracks/contiguous with annular seal Yes W1 -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 U1 No ❑ NA❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NAM Chlorination port available and sealed properly Yes 0 No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and tJo Sc `ihs check valve or within 3' of well head Yes ❑ No [A 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 ❑ INA Air gap of at least 6" (same as pipe diameter) Yes ❑ JNo ❑ INA F0 MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA❑ Well/Pump free from excessive vegetation Yes 0 No ❑ INA[] _ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ Permit drawing sufficient to locate well in future Yes [a' No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes [0 No ❑ OTHER: Comments: Inspected By: Ow, SO Title: Received By: Date: _