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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.swgov.org/ehd <br /> PUMP SURVEY CHECK LIST <br /> Address: Permit#: Inspeo'don Date: <br /> 19960 N. ELLIOT <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 installed Yes ® No ❑ N/A ❑ <br /> Dimensions of surface seal 2'x2'x4' minimum Yes ® No ❑ WA ❑ <br /> Casing extends at least 1`above pedestal Yes ® No ❑ WA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ N/A <br /> Graded to allow drainage away from casing Yes_Z No ❑ NIA ❑ <br /> Other Yes ❑ No ❑ N/A ❑ <br /> SanitB Seal' (SIC Ord. Trtfe 9, Ch ger 9-1115,SJC Well Standards Sections 4.11;4.12) <br /> Well is sealed between pump and surface seal(top mounted pumps) Yes ® No ❑ WA ❑ <br /> Sanitary seal between pipe columns and casing water tight Yes ® No ❑ N/A ❑ <br /> Soundinglair tubes water tight/downward 'inverted/16-mesh screening Yes ❑ No ❑ N/A <br /> Chlorination port available and sealed water tight Yes ® No [—j WA ❑ <br /> Other Yes ❑ No ❑ N/A ❑ <br /> Sampling Tap and Backflow Prevention: (SJC Ord. Tft 9, Chapter 94115,-SJC WeR;fandards <br /> Sections 4.13;4.14 <br /> Non-threaded sample tap between well head and check valve or within <br /> 3'of well head Yes ElNo ❑ N/A ® WRAPPED W/ FOIL <br /> Adequately installed check valvesFPaernm) Yes ❑ No ❑ NIA <br /> No cross connections(wda.;mirwa,,,hook9dwd, buflonsyst WWCw Vifflg e„ .Yes El No ❑ N/A rmm m <br /> Air gap Of at least 6'(!2"„pip.d ,,,,w) _ Yes ❑ No L] N/A <br /> Other Yes ❑ No ❑ WA ❑ <br /> Miscellaneous: (SJC Ord. Title 9, Chapter 9-1115,SJC Wall Standards 5.00 <br /> Well is in use and capable of functioning as originally designed Yes ® No ❑ N/A ❑ <br /> Weil/Pump visible and protected from da22NE Yes M No ❑ WA ❑ <br /> WeIVPump free from excessive vegetation Yes ❑ No ® N/A ❑ <br /> Permit drawl represents actual location of well Yes N No Ll NIA H'rxi is selected,attarn an accurate <br /> Permit drawing shows sufficient detail to locate well in future Yes No NIA map to permit <br /> Other Yes Ll Ll N/A <br /> ❑ <br /> Comments• <br /> WELL APPEARS-VO BE SEALED AND IN FAIR TO POOR CONDIT. SEAEL1l rELLHAEAD CAP IS THIN AND <br /> RUSTING. PIPES WRAPPED WE ALUM. FOIL. SMALL TANK, WATER FACET IS OPERATIONAL. 517/08 <br /> Inspected By: Tide: SENIOR REHS <br /> Recr_4ved Py: Date: <br /> 4V 7 <br /> Vnir <br />