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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> — 1.86.8_East_HazeLtonAvenue,3tQc_loan, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.org/ehd <br /> -- PUMP CTF0-WCFIECKCIST --- — <br /> Address: Permit#: Ins ection Date: <br /> joq2at-1 q-�,/7' r--,I4c" P O Ko 0 <br /> Parameter/Standard Meets SJC Standards? Com mentslMeasurem ents/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes M No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes [A No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes W No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ 1 NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing —YesV- No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes V No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA W1 <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 [V No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes Rj 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 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes a( No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA El <br /> MISCELLANEOUS: ,- <br /> Permit <br /> ISCELLANEOUS: .Permit drawing represents actual location of well .Yes V No ❑ <br /> Permit drawing sufficient to locate well in future Yes [V No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 9 No ❑ <br /> OTHER: <br /> Comments: Clt l C ,� w <br /> Inspected By: CLA, .tel Title: -),vl /t ��( HeQ �1f <br /> Received By: Date: <br /> �,�a 1-4 <br />