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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.oM ehd PIMP INSPECTION CHECK LIST Address:Perm o S - - H AIEZ leuRs s'c� o /J D �"� Insp ctio Date: 01 08 aoN Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes V No ❑ NA ❑ Casing extends at least 1" above pedestal Yes M No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes [A INo ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ I NA ❑ Sounding tube/air vents sealed properly Yes ❑ No R. NA Chlorination port available and sealed properly IYes ® 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 ❑ �NAE] Adequately installed check valve or BFP device Yes No ❑ INA ❑ 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 IYes ® No ❑ NA ❑ Well/Pump free from excessive vegetation IYes 7 No ❑ INA ❑ MISCELLANEOUS: - Permit drawing represents actual location of well Yes E2 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 Yes [Z No ❑ OTHER: Comments: ' Inspected By: J(� Received By: Title: 1tSS tJ f' Date: RN I /gni