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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.org/ehd PUMP INSPECTION CHECK LIST Address: JI / y� Permi 2- 0T L"i c{ v'�Ci'C �✓/�� a� Jl %1 I/S P ©o 3. 9 In ate: I �/ z i Parameter/Standard Meets SJC Standards? Com m ents/Meas u rem encs/Recommendations 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 9 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 tube/air vents sealed properly Yes No ❑ 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 eon 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 ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ❑ No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ❑ No ❑ Photograph taken and attached to record Ye No ❑ OTHER: Comments: g P m PV I L Qk— / �' 1 W 5 Gf ��i S 1 cL�� ri�i G� 7�S V -e idi Ms Qss �y Ave C(q'"Vrt& Co Inspected By: Vj Title: ic Received By: Date: on cu n0011 ❑iQaion ar