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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95206-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web; www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: e C0 PPERD o X16 �� L?��> Permi • 00 3 Inspe tion ate; t Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4n minimum) Yes [a Casing extends at least 12" above grade Yes ® WNAD Casing extends at least 1" above pedestal Yes ® Free of cracks/contiguous with -annular seal Yes Graded to- allow drainage away from casing Yes Qj No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ - Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents eealed properly Yes ❑ No ❑ NA 2 Chlorination port available and sealed properly Yes W jNo ❑ NA SAMPLE TAP AND BACKFLOW PREVENTION: irw Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No Ell NA [� Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic sup ly) Yes ❑ No ❑ NA fZ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA IV 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 JZ N-60 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 [V No ❑ OTHER: Comments: inspected By: / �4 Title V' f1AVA'(Q Received By: I Date: