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��PIJN5 JO/kOMIN)COUNTY <br /> ENVIRONIVIENT AL HEALTH DEPARTMENT <br /> '1868 East Ha7elton Avenue, Stiock' n, CA 95206-6232 <br /> L LO <br /> Tefcaphone:(209)468-3420 Fax: (209)468-3433 t//els:vv\wv.siqov,oj-g/ehd <br /> P U M1 P I N S1 P E 0 T 10[\] C H,E G K' L i E-31" <br /> Addr6ss: • Permitil: Inspection Date7- <br /> Pai-au-ne-teriStandard Rheeis SJC S-Mr.dards? <br /> Recoi-,uneiidatimis <br /> CIEMIENT PEDESTIAL., <br /> Dimensions Of Surface seal (2'x2'x4" minimum) Yes Kh I N,o F-1 NIA El <br /> Casing extends at least lZabove grade Yes No ❑ NA <br /> Casing extends at least T' above pedestal I YesINo [INA E] <br /> I <br /> Free of cracks/contiguous with annular se2.1 IYes I INo 0 INA El I <br /> Graded to allow drainage away from casing 1'\,/es j I No Ll I NAE] I <br /> SANIFFARY*SEAL: t <br /> IWell is sealed between IDUrnp and casing Yes I No [:1NAE1 <br /> Seal between all pipe columns and casing Yes No 0 INA <br /> SOU11dir1g tube/air vents sealed properly Yes No El INA El II <br /> Chlorination port available and sealed properly Yes No NA <br /> SAMIPLET-AP AND BACKFILOIA1 PREVENTION: <br /> Non-threacied sample tap between well head and IYes <br /> check valve or within Tof well head No ❑ I1NA ❑ <br /> Adequately installed check valve or BFP device IYes [j No 0 1 NIA El I <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from orni dornestic SLII:)I)ly) Yes El No 1 1 NA <br /> Air cap of at least 6" (same as pipe diameter) I Yes El No El INA &II I <br /> II <br /> MAINTENANCE <br /> VVellfPump visible and protected from damage Yes <br /> Well/Pump free from excessive vegetation Yes if\100 El !\Ij-', El <br /> 0 I1NAE] <br /> Fiel IS C E L LAN E--'O U S: <br /> Permit dravving represents actual location of well Yes INoE1 <br /> Permit drawing sufficieritto locate well in fi-I'Ll-TeIVes No E] If'no'is selected,attach an accurate map to permit <br /> I <br /> Photograph taken and attached to record IYes [A I No El <br /> 10THER: <br /> 'coninients, <br /> C)QAA�- <br /> hispected By: ITitle: <br /> Received By: Date: <br />