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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1-86.8-East_Hazelto.n_Aveaue,-at2cktQn, CA 96205-6232 <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> -- -- - --PUMP INS POGT[DWGFIF-CK-LIST- <br /> Addr6ss: f V t � F 4 6� � � L oj) ( Pe-S P 0"� Inspection116Dat; <br /> (? N • �J 1, h T <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes 9 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 12 No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes 0 iNo ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes U No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly—&V]No ❑ INA❑ <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 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NAV <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Weli/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation YesV No ❑ NA[] <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well .Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes [ No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yeb No ❑ <br /> OTHER: <br /> Comm nts: <br /> Inspected By: <br /> Received By: Date: <br />