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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.sigov.org/ehd PUMP INSPECTION CHECK LIST r:u nonn oroa rnnac Address:Permi 0 IJ o� A-nJ U S i (,V-Tp�.l 1� h8- 3 49'71 Insp ctio Date: 01 ti I �1 Parameter/Standard Meets SJC Standards? Comments/Measurements) Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [� No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal _YesD No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [V No ❑ NA ❑ Seal between all pipe columns and casing Yes 9 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA V Chlorination port available and sealed properly Yes ❑ No ❑ NA EM SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA �] Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/2g flood irrigation from domestic supply) Yes ❑ No ❑ NA [� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes © No ❑ NA ❑ Well/Pump free from excessive vegetation Yes © No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 2 No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [ No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: rwic Inspected By: V0, Title: t+` A ff j 4. LI Received By: Date: r:u nonn oroa rnnac