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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 1:u norm o,od,nn�c Address: 6C0� 85 %J Sl 62E i AV C ,�k�1 Permi Wrb v `_� j q 38 Inspe tion Date: 0� z8its Parameter/Standard TMeets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [A 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 Q No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes Ej No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA N, 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 © 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 2 MAINTENANCE: Well/Pump visible and protected from damage Yes [Z No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Fj No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes © No ❑ If `nog is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes © No ❑ Photograph taken and attached to record Yesj7� No ❑ OTHER: Comments: s� �f!/'f YU7 �1 �,�{ , (,� �i i".� c� k.•te_ lQ, v� � f�,-�tLn•' � f'th1 -�-�' P . Inspected By: Ltav �� Title: ('' < ��113 Received By: Date: 1:u norm o,od,nn�c