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r <br /> P <br /> I A 4 0V <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1-868 East_Hazeltongveaue,_S-tn.cktou, CA 95205-6232 _ <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orq/ehd <br /> - - -- PUMP I PECTTOWGREGKUS <br /> Address: Permit#: Insp131 14 <br /> ection ate: <br /> /J UCL SI v Cr AC.Arv►PO fL O 7 7 5 o <br /> Parameter/Standard Meets SJ Standards? Comments/Measuremei <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes EZ No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes KA No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes M No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes © No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes R4 IND ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [V. No ❑ NA❑ <br /> Seal between all pipe columns arld casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes[4 No ❑ NA❑ <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 KI No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes&4 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes❑ No ❑ NA bZ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes Q( No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 11 No ❑ NA <br /> MISCELLANEOUS: , <br /> Permit drawing represents actual location of well .Yes U 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 Yes No ❑ <br /> OTHER: _ <br /> Comments: <br /> N npwP� 1nS�ef( �� �'�.� n^o �- r}v G� 1(t (,U S'�t.ti. 9 1-e <br /> Inspected By: - _l S� Title: l�M>�.f�L_��►(k A41' <br /> Received By: - Date: - <br />