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SAN JOAQUIN]. E:>OUN T Y <br /> ENVIRONIMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Vifeb:yv\vW.sigov.orq/ehd <br /> PUMIP INSPECTION CI'HECK LIST <br /> i�,ddress• Perm' �Insp4iion a� <br /> ' <br /> a s• JACk 1046 A � si ci�k --- �,JVDl� 8 6 ,2` �ir <br /> I` <br /> Para;rre'cer/standard Meets SJC Standards? Com m entslMeasurem encs/ i <br /> Recommendations <br /> jCE[VIENT PEDESTAL: --li <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes © I No ❑ INAE] <br /> 'Casing extends at least 12" above grade Yes No ❑ INA❑ <br /> (Casing extends at least 1" above pedestal Yes W1 No ❑ INA ❑ <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 /> IVVell is sealed between pump and casing Yes [j I No ❑ NA ❑ <br /> 'Seal between all pipe columns and casing Yes I INo ❑ NA ❑ j <br /> (Sounding tubefair vents sealed properly Yes No ❑ NA ❑ <br /> !Chlorination port available and sealed properly Yes ❑ No ❑ NA j <br /> 'SANOPLE TAP AND BACKFLOI,r>_I PREVENTIOM <br /> ,Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes ❑ lNoo�NAW <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 ❑ NA I� <br /> jAir gap of at least 6" (same as pipe diameter) I Yes ❑ INoD NAV <br /> MAINTENANCE: <br /> iVVell/Pum visible and protected from damage Yes <br /> i I 1 g L_,� INo ❑ NA❑ <br /> - <br /> Well/Pump free from excessive vegetation Yes V No ❑ NA❑ <br /> THSCLLLANEOUS: <br /> Permit drawing represents actual location of well `r`es No ❑ I' <br /> Permit drawing sufficient to locate well in future (Yes I No ❑ l 'no'is selected, attach an accurate map to perms <br /> ;Photograph taken and attached to record Ives No ❑ <br /> a <br /> �Crol��mer�'i�: <br /> II <br /> t vw at,"t6 <br /> i' Il <br /> .InspectedY ------ -- I— .tJIJ � <br /> i3 •: Ola. <br /> i <br /> I,Received By: I Date: <br /> r-u ^nn <br />