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SAN JOAQUIN] COUKITY ENIVIRONIVIE11111TAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-34.33 14,'eb:vvm1v.sjqov.orq/ehcl PUMP WSPECMN CHECK UST Sir IC4 1 Address: Permi Ins ec" Date: NqOO W . Sc4u /TF )Ej._� C7 I z PararneterfStandard Meets SJC Standards? Comments/Meas I Recommendations GEMENTPEDESTA,L, Dimensions of surface seal (2'x2'x4" minimum) Yes No 0 I NA Casing extends at least 12" above grade Yes 2 No F1 NA F-1 ,Casing extends at least 1" above pedestal Yes J2 No ❑ NA Ej Free of cracks/contiguous with annular seal Yes RI No D NAE] II !Graded to allow drainage away from casing IYes 9 No El I NA ❑ ISANITARY SEAL: Well is sealed between pump and casing Yes 0 No F N !,Seal between all pipe columns and casing Yes IND 0 NA ❑ Sounding tube/air vents sealed ealed properly Yes ❑ IND ❑ NA ❑ !Chlorination port available and sealed properly Yes No ❑ NA SAMPLE TAP AND BACKFLOW PREVENTION: lNon-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 V JNoE1 NA 0 kk 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 ❑ No ❑ NA MAINTENANCE: ;Well/Pump visible and protected from damage IYes No ❑ NA from excessive vegetation Well/Pump free n IYes No ❑ NA El �,MISGELLANEOU-S: drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes 2 NoEl 11'no'is selected, a-Li2ch an accurate M2P to permit IiPhotograph taken and attached to record Yes No El 10TH 'E-R: Comments, 11 Inspected By: V� Title: Received By: I Da-LC-:: uu r-1-1 A^rlrl