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` - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.oro/ehd PUMP INSPFCTinN CHFrK 1 14T Address: © S >� C, Parameter/Standard j Meets SJC Standards? Fermi a 3�i Inspe �1 tion Date. o 6S z o8 l Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least V above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes EW No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes D INo ❑ NA ❑ Seal between all pipe columns and casing Yes No El INA ElSounding tube/air vents sealed properly Yes ❑ No ❑ INA EV Chlorination port available and sealed properly IYes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes IV No ❑ ❑ Adequately installed check valve or BFP device Yes [V No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA E�' _ --- Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAM MAINTENANCE: Well/Pump visible and protected from damage Yes Well/Pump free from excessive vegetation Yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments% No ❑ INA No ❑ INA Yes'/}j No ❑ Yes LANo ❑ If 'no' is selected, attach an accurate map to permit Yes VNo Inspected By: V OLA. Title: Received By: Date: cu n�nn