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' SAN JOAQUIN GoUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; www.sigov.orcl/ehd PUMP INSPECTION CHECKLIST Address: (J � 433 ��C Permit#: V_ „rb A Inspection Parameter/Standard Meets SJC Standards? Comments/Measuremenfis! Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4U minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes 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 No ❑ NA ❑ Sounding tubelair vents sealed properly Yes ❑ No El NA � 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 ❑ 1 No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation INIA from domestic supply) Yes ❑ No ❑ [V7 Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ INA MAINTENANCE: Well/Pump visible and protected from damage Yes [2 No ❑ NA ❑ (Nell/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Pen -nit drawing sufficient to locate well in future Yes No❑ If'no' is selected,�attachnaccurate map to permit Photograph taken and attached to record Yes [ No ❑ OTHER: Comments: I" LLA -Y 1"w we,4 t`l►xP"'Ad ILI nspected By: VO -10 r.l ` O Title; H&�fS . l teceived By: Date; I cu n Dnn