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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:www.sjgov.org/ehd <br /> PUMP Q@ SPECTM M 9ECK LIST <br /> Address: Permit#: Inspection Dace: <br /> 1001-\AA �j C)p 3aa3 I <br /> ParameterlStandard Meets SJG Standards? Com met tslMeasurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes rq No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 9 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Sj No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns aiid casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No ElNA [:1Chlorination 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 �7No ❑ NA❑ i <br /> Adequately installed check valve or BFP device Yes Q No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No J�h NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ INo ❑ INA[j <br /> FWAINTENA:NCE: <br /> Well/Purnp visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 01 No ❑ NA❑ <br /> FOISCELLANEOUS: i <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in futureYes No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments" j <br /> Inspected By: Title: <br /> Received By: Date: <br /> 1 n fn.l InnA G <br />