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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efc-phone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.oM&t d <br /> _ PUMP INSPEC[MN CHECK LISA' _ <br /> P:ddress: Permit#: Inspection Date: <br /> 71 <br /> �Q'3.� 05 2d <br /> Parameter/Standard Meets SJC Standards? <br /> C o a i meats/Meas ntdl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ° I No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V 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 No ❑ NA❑ <br /> SANITARY SEAL.: <br /> Well is sealed between purnp and casing Yes No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes j No ❑ INA❑ <br /> Sounding tube/air vents sealed properly - Yes g No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes 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 �j No ❑ NA❑ i <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 ❑ jNo 4 NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[ ] <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 01 INo ❑ NA❑ <br /> MISCELLANEOUS: I <br /> Permit drawing represents actual location of well Iyes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ Il'no'is Selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> 6u\ <br /> Inspected By: Title: <br /> Received By: Date: <br /> -- nrna rnnao <br />