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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.siclov.orq/ehd PUMP INSPECTION CHECK LIST k -VIII erlL.D. Inspected Received By: . I Date: Gu n)nn Atlar ss^ ` _ ✓ l ' / f�� 1`v n C / `O�)/'I�"/ Vnl /v f6G• rT Para meter/Standard Meets SJC Standards? Perm' 1 D'3 Inqcti °n ate: 11,0111114 - CornmentsiMeasurementsi 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 I" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [0 No ❑ NA ❑ Graded to allow drainage away from casing Yes LA No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes%NoEED]l NA ❑ Seal between all pipe columns and casing YesNA ❑ Sounding tube/air vents sealed properly Yes ❑NA Chlorination port available and sealed properly YesNA ❑ 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 systemlag flood irrigation from domestic supply) - Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA V 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 YesVNo 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes If Photograph taken and attached to record Yes OTHER: %�- -- --rte_. k -VIII erlL.D. Inspected Received By: . I Date: Gu n)nn