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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.slgov.org/ehd PUMP INSPECTION CHECK LIST Address:l�� CA-rJ rol L I N �Cj P=6038 D IDpe�/ Il e: Parameter/standard Meets SJC Standards? Comments/Measurements/ r:ecomrnendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes © 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 No ❑ NA ❑ Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ Sounding tubelair vents sealed properly Yes ❑ No ❑ NA [� Chlorination port available and sealed properly Yes [0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes EZ No ❑ NA ❑ Adequately installed check valve or BFP device Yes V No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 521 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [� MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ 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 M No ❑ Yes No ❑ Yes [A No ❑ If `no' is selected, attach an accurate map to permit Comments• ^ -�G f CQ (Ax"V I 11 k, �� P�,,, Inspected By: " Received By: Title: Ass Ks Date: