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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.orglehd PUMP INSPECTION CHECK LIST Addre S: K1 Tu�PerrrytP sud " 's-DCikLA) �� I I16A Ite: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 2 No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes W No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes 0 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes j2 No ❑ NA ❑ Seal between all pipe columns and casing Yes 2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Qj Chlorination port available and sealed properly IYes 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 fj,. S` Adequately installed check valve or BFP device Yes Qj 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 ❑ NAV MAINTENANCE: Well/Pump visible and protected from damage Yes LA No❑ENA El Well/Pump free from excessive vegetation Yes ® No ❑ ❑ 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 2 No ❑ Photograph taken and attached to record Yes 0 No ❑ OTHER: Comments: Inspecte Title: U1{))h1n(w ( t/ i Received By: Date: I:" ne�nn ❑ria r0nqc