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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Flazelton Avenue; Stockton, CA 95205-6232 <br /> 'relephone:(209)468-3420 Fax.,(209)468-3433 Web:www.sjqov.ora/ehd <br /> PUMP INSPECTION CHEEK 1-115'r <br /> 0 T� <br /> tionp <br /> spe'p 7, <br /> nr <br /> Address" Per 1; <br /> ate:03R8 <br /> CommentslMeasurements/ <br /> Parameter/Standard Meets SJO Standards? Recomi-nendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes E� J0a NA[j L <br /> C asiPp.extends atleast12' aboye_,qrade Yes 9 No NA <br /> Casing extends at least 1" above pedestal Yes Q No Ej NA F <br /> Free of cracks/contiguous with annular seal Yes No OINA <br /> Graded to allow drainage away from casing Yes 91No01NA_ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casinq Yes No NA❑ <br /> vA.I.al between all pipe columns and casino Yes.U_jNo NA <br /> syung!aaj!j� air vents sealed goptrly Yesj oj,7 <br /> ChlorlinatiOn Port available and sealed ProPeqy-2yAeQ-.,Nq1j- N&D--L <br /> SAMPLE TAP AND BACKPLOW PREVENTION: —------- <br /> Non threaded­sample tap between well head and r'fo <br /> check valve or within 3' of well head -- Yes El No a NAQ_ <br /> 2Adequat�q I installed check valve or BFP device Yes 2_ No [I NA El ------------ <br /> No cross connections (ex: chemical feeders <br /> Looked to distribution system/ag flood irrigation <br /> from domestics. 1 Yes E] No [I NA 0-1 <br /> ,�IE�a _q�at least 6" (same as pipe diameter) IYes El QNo JN:A:D t <br /> MAINTENANCE: <br /> Nell/Pump Visible and protected from darna e Yes NoE] .NAEL_ <br /> Well/Pump free from excessive vegetation Yes No [1, NA[:1 <br /> MISCELLANEOUS: ......... <br /> Permit drawing represents actual location of well Yes No <br /> Permit drawing sufficient to locate well in future Yes lf'no'Is selected,attach an accu?ate map to permit <br /> Photograph taken and attached to record Yes No <br /> OTHER, <br /> Comments: <br /> .te <br /> f-,Inspected_ � rjS6 Title: �4 <br /> Received By: Date: <br />