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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 Address: d si V Ew -bP 5T-C,c1cA Permit#: P,001S008 Inspe tion ate. t`�t t: 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 1" above pedestal Yes U 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 g No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA 0Y Chlorination port available and sealed properly Yes 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 ❑ 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 supply) Yes ❑ No ❑ NA [� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 0 MAINTENANCE: Well /Pump visible and protected from damage Yes K ] No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes kj 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 V No ❑ OTHER: Comments: Inspected By: a� r t Title: Received By: Date: n -1n 4C