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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 Ad ress• ivlo �E-� �TDc.(G /J Permit#: Inspection Date: Szao��o~7� lvl'/z 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 [2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes U No ❑ NA [] Free of cracks/contiguous with annular seal Yes [v] No ❑ NA ❑ Graded to allow drainage away from casing Yes [2 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 19 No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA &WPQh/ Chlorination port available and sealed properly Yes Wr 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 ❑ "1' ` Adequately installed check valve or BFP device Yes Z 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 ❑ NAY 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 IYes k2 No ❑ is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future YesV No ❑ lf'no' Photograph taken and attached to record Yes [V No ❑ OTHER: Comments: (vo Ck P Inspected By: V QM Title: E",y1?Uiimza Received By: I Date: