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SAN J OAQUIN. C+OUN T Y ENVIR0N1\AENTAI_HEALTH DEPARTMENT 1868 East HazeltOn Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web:Mrvvd.sjgov.orq/ehd PUMP IN"PEC T ION1 CF1EC_X UST Address, Pe- r�:; -_— Inspe tion ate: i NF,LEt! L/J Sn (-tcTb�J 0o3gS3Z tz �� r �y �r Pararneter/Standard Meets SJC Standards? Commentsffleasurementsl i Recommendations CEMENT PEDESTAL: I! U Dimensions of surface seal (2'x2'x4" minimum) Yes © I No ❑ NA❑ Casing extends at least 12" above grade Yes 1 No ❑ INA ❑ ;Casing extends at least V above pedestal Yes No ❑ NA ❑ 1 ;Free o ccracks/contiguous with annular seal Yes D No ❑ NA ❑ 'Graded to allow drainage away from casing Yes Q No ❑ NA ❑ (SANITARY SEAL: Well is sealed between pump and casing Yes No ❑INA ❑ Seal between all pipe columns and casing IYes No ❑ NA ❑ I j ;Sounding tube/air vents sealed properly Yes ❑ I No ❑ INA [V jChlorination port available and sealed properly Yes INo ❑ NA ❑ t SAIIFLE TAB AND BACKFLO it PREVENT"ISN: I� Non-threaded sample tap between well head and cl peck valve or within 3' of well head 1'es [�l No ❑ INA ❑ i Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders (hooked to distribution system/ag flood irrigation !f]-om domestic supply) Yes ❑ No ❑ NA ® i Air gap of at least G" (same as pipe diameter) Yes ❑ No ❑ NA Q j !MAINTENANCE: VVell/Pump visible and protected from damage IYes No ❑ NA❑ ;I Well/Pump free from excessive vegetation Yes No ❑ NA❑ M' ISCELLfzNE©US: i Permit drawing represents actual location of well Yes No ❑ j Pemnit drawing sufficient to locate well in future Yes ❑✓ No ❑ 11 no'is selected,a<iach an accurate map to permit Photograph taken and attached to record Yes No ❑ 'OTHER: Comments. Il J Vi I I� ii J *� l r L F 'inspected i3v: � _ (Title:. 4.SSIJ a Received By: _ I Date: r-u r^nn ni�a rnr.