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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: AvE �STPcL-"b /j Permit#: SP-oo-7 07 Inspection ate: v/ 0y l� Parameter/Standard Meets SJC Standards? Cornments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [ No ❑ NA ❑ Casing extends at least 12" above grade Yes ❑ ❑ 11 c �� -�� } 12 4 6auc Casing extends at least V above pedestal Yes ❑ Nog INAD ems `,, ry,�t Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes 0 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [2 No ❑ INA ❑ Seal between all pipe columns and casing Yes [Z No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA P 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 [a No ❑ NAD 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 2 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [j? MAINTENANCE: Well/Pump visible and protected from damage Well/Pump free from excessive vegetation Yes 0 Yes ❑ I No ❑ INA No MI ❑ NA ❑ I/e .e �� MISCELLANEOUS: Permit drawing represents actual location of well Yes 2 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 [� No ❑ OTHER: Comments: `' I l ,-e X �-��i J T 12 1 I a J tc�,, (S r V Inspected By: r-jS Received By: Title: Y:) Ss I'J Q k Date: f