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8 # SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd PUMP INSPECTION CHECK LIST C:u eonn 0i1�1 rind c Address: j 0 ` ►►� - 1 �`` ` �• /� M� l 1 U/�/ Insp tion/Date: Pe bo -7-7-7o? r5W- Pararneter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [0No ❑ NA ❑ Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes Y No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [4 Seal between all pipe columns and casing Yes 0 Sounding tube/air vents sealed properly Yes ❑ TWEDINAED V Chlorination port available and sealed properly Yes 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 LJ No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [V 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 V1 No ❑ lf'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 :Y& s No ❑ OTHER: Comments: Inspected By: OLA O Title: f I rV""rA- +, —' 14:1J Received By: Date: C:u eonn 0i1�1 rind c