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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fox: (209) 468-3433 Web: www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: L (�J - i g e f v C i- - KD, -C-S *'� W//, C A L O Permi�:&V3T76 nspe1 17o333 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) YesD No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA [:1 Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 10 No ElGraded to allow drainage away from casing Yes (� No F�NA A ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ kNAE]Seal between all pipe columns and casing Yes No El❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [vj Chlorination port available and sealed properly IYes FJ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Q No ❑ NA ❑ Adequately installed check valve or BFP device Yes UL No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ INoD INA Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ 1 NA [ MAINTENANCE: Well/Pump visible and protected from damage lYesUl 1NoDjNAD Well/Pump free from excessive vegetation IYes U INo ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Yes D Yes Yes_a No ❑ NO ❑ No ❑ if 'no' is selected, attach an accurate map to permit Comments: ' Inspected By: Received By: Title: ,S' Date: