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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.orq/ehd PUMP INSPECTION CHECK LIST Addre s: 78 Toc.l� �� L�nIJ Perm w' tx� _37±2IIle)ll Inspection Date: - r Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [2 No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 9 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 [0 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes [A No ❑ NA ❑ Chlorination port available and sealed properly Yeso No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No V NA ❑ ��(,( I rY i G Adequately installed check valve or BFP device Yes La No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [j Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [q' 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 ® No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes F/I No ❑ Photograph taken and attached to record Yes M No ❑ OTHER: Comments: Inspected By: �lM I S Title: Env `r "f' d qj&' t ff A141 Received By: Date: aialronir