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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 Address:Permi rY1 A*'I C C A S J� !}�vT 6.04 0 0 Inspection Date: 0g42 �. 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 V above pedestal Yes 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 0 No ❑ INA ❑ Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA Y Chlorination port available and sealed properly I 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 V MAINTENANCE: Well/Pump visible and protected from damage Yes Q No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No 51 NA ❑c V,t 4-a �,,,-,, MISCELLANEOUS: Permit drawing represents actual location of well Yes Ll No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Lj No ❑ Photograph taken and attached to record Yes Elf No ❑ OTHER: Comments: Inspected By:y Cq,(4 Title: 60I rD"ffUMjgj Near , Received By: Date: