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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.sjgov.orq/ehd PIMP INSPECTION CHECK LIST Ad ess:a . STb C ICTb N P'S 0 O-7 6 g l date: 0 pe tion Parameter/Standard Meets SJC Standards? Comments/IV s/M Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No k2 NA ❑ (-C 'm.¢ iu., j 14J Casing -extends at least 12" above grade Yes F2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [Z No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes ® No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes E '' No ❑ NA ❑ Seal between all pipe columns and casing Yes [n No ❑ NA ❑' Sounding tubelafr vents sealed properly Yes [A No ❑ NA ❑ Chlorination port available and sealed properly Yes V No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [j No ❑ NA ❑ Adequately installed check valve or BFP device Yes V 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 Yes4Z No ❑ NA ❑ Well/Pump free from excessive vegetation Yes KZ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes 9 No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 2 No ❑ Photograph taken and attached to record Yes 9 No ❑ OTHER: Comments: I�r�Ct,�R, GV>rl�-nsL� Inspected By: aAN SQ Received By: Title: Date: