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SAN JOAQUIN COUNTY <br /> L-ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> PUMP SURVEY CHECK LIST <br /> tress: Permit#: Inspection Date: <br /> ba <br /> / Parameter/Standard Meets SJC Comments/Measurements/ <br /> Standards? Recommendations <br /> Cement Pedestal:(SJC Ord. Title 9, Chapter 9-1115,SJC Well Standards Section 4.10) <br /> Surface seal installedYes No r❑-�'N1/A E]Dimensions of surface seal(2'x2'x4"minimum) r Yes [-No [kN/A ❑ <br /> Casing extends at least 1"above pedestal Yes ❑ No [9'N/A ❑ <br /> Free of cracks/contiguous with annular seal I Yes ❑ No ❑ N/A <br /> Graded to allow drainage away from casing lYes ❑ No ❑ N/A <br /> Other Yes [rte No ❑ N/A ❑ <br /> Sanita Seal: (SJC Ord. Tltle 9, Chapter 9-1115;SJc Well Standards Sections 4.11:4.12) <br /> Well is sealed between pump and surface seal (top mounted pumps) IYes [a- No ❑ N/A ❑ <br /> Sanitary seal between pipe columns and casing water tight Yes ❑ No ❑ N/A [3- <br /> Sounding/air tubes water tight/downward inverted/16-mesh screening Yes ❑ No ❑ N/A <br /> Chlorination port available and sealed water tight Yes Ek No ❑ N/A ❑ <br /> Other I <br /> Yes ❑ No El N/A ❑ <br /> Sampling Tap and Backflow Prevention:(Sic Ord. Tale 9, Chapter 9-1115;SJC Wea Standards <br /> Sections 4.13;4.14 <br /> Non-threaded sample tap between well head and check valve or within Yes (9--No El N/A El3'of well head <br /> Adequately installed check valve(«d r aFP devke) Yes t[3�No ❑ N/A ❑ <br /> No cross connections feeders hooked b daft'Aw sysreMeg nom�nigw'. yes C1 NO El N/A <br /> item do sl[c <br /> Air gap of at least 6"(same as pae disme,e) Yes ❑ No ❑ N/A <br /> Ither Yes ❑ No ❑ N/A ❑ <br /> iseellaneous: SJC Ord. Tale 9, Chapter 9-1115;SJC Well Standards 5.00) <br /> Well is in use and capable of functioning as originally designed Yes No ❑ N/A ❑ <br /> Well/Pump visible and protected from damage Yes [a- No ❑ N/A ❑ <br /> Well/Pump free from excessive vegetation Yes ❑.No ❑ N/A ❑ <br /> Permit drawing represents actual location of well Yes [ta'No ❑ N/A ❑ lf'no'is selected,attach an accurate <br /> Permit drawing shows sufficient detail to locate well in future Yes ❑ No ❑ N/A ❑ map to permit <br /> Other Yes ❑ No ❑ N/A ❑ <br /> Comments- <br /> (JV2Pl2_ iS t A.vvu�Ke,,, '^Zt c)pr_ t$� / SFS rf YO�CUL—+ <br /> 7 0 <br /> s eted By: Title: SENIOR REHS <br /> Received By: Date: <br /> S3 .U9'A) <br />