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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 Aaaress% Q (j VQui C-• 8R- QD j'0—b , Per oo376a� W Inspsctio ate: Parameter/Standard — Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum]Yes; Yes Y No ❑ NA El- Casing extends at least 12" above grade Yes No El INA El Casing extends at least 1" above pedestal No ❑ NA❑ Free of crackslcontiguous with -annular sealYes g No ❑ NA ❑ Graded to- allow drainage away from casing IYes M No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing I Yes ® INoDINAD Seal between all pipe columns and casing Yes hANo ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [ Chlorination port available and sealed properly Yes INo ❑ NA 51 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 Yeso No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA R1 - Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAV MAINTENANCE: Well/Pump visible and protected from damage Yes V No ❑ NA ❑ Well/Pump free from. excessive vegetation Yes VI No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes �A 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: Inspected By: Title: ` ►1/1'U"tq( k111k k l� t Received By: Date: