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i <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East HazeltOn Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:vArfVv.sjgov.orq/ehd <br /> PUMIP IINSPEC T ICON CHECK _IST _ <br /> � dress: � _ -- Per i-- -- Ins e zton ate:_ <br /> Parameter/Standard Meets SJC Standards? Comments/Arleasurements/ <br /> Recommendations <br /> ,CEMBilT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ® I No ❑ NA❑ <br /> i <br /> Casing extends at least 12" above grade Yes V No ❑ NA ❑ l <br /> Casing extends at least 1" above pedestal Yes © No ❑ 1 NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: I� <br /> .I <br /> Well is sealed between purnp and casing Yes No ❑ NA ❑ � <br /> Seal between all pipe columns and casing IYes [fV No ❑ NA ❑ JJ <br /> ;Sounding tube/air vents sealed properly Yes 0 No ❑ NA ❑ I <br /> Chlorination port available and sealed properly Yes No ❑ INA ❑ ((' <br /> SAMPLE TAP AND BACKFLOW PREVENTION: II <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes V 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 Ii <br /> Trom domestic supply) Yes ❑ No ❑ NA ©? <br /> jAir gap of at least 6" (same as pipe diameter) Yes ❑ INoD NA [V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> 'Well/Pump free from excessive vegetation Yes [ No ❑ NA❑ I ' <br /> .ti>11SCELLt-,NE�IJS: h <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes ® No ❑ I 'no'is selected, a«ach an accurate map to permit 1 <br /> Photograph taken and attached to record Yes [71 No ❑ i <br /> 'OTHER: <br /> Comments: - -------- --- -- <br /> t ce X-" <br /> I � <br /> 1hispected By: S —----- -- Title: 44 • AfSIJTCvd , <br /> I1 Received By: Date: <br /> �u <br />