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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.orq/ehd PUMP INSPECTION CHECK LIST uwess' Permit: Inspection Date; J G 1' hr 2, r1 a l' !_ 1 n n rC %CF\ S T),-,/ /s ?kti I I 1 Al 1� n n '2 17 / - / I .. I- _ i - Parameter/Standard - -.� _ • v L11A If/ Meets SJC Standards? Comments/Measurements/ Recommendations GEMENT PEDESTAL: YeS 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 V above pedestal Yes [0 No ❑ NA ❑ Free of crackslcontiguous with -annular seal Yes g No ❑ NA ❑ Graded to- allow drainage away from casing Yes No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes JZ I No ❑ fNA ❑ - Seal between all pipe columns and casing Yes 6Z No ❑ NA ❑ Sounding tubefair 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 2 1NoE1 INAE] Adequately installed check valve or BFP device YesV iNoDINAF] No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ 1 No ❑ NA IV Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA hZ MAINTENANCE: WeIVPump visible and protected from damage Yes Well/Pump free from. excessive vegetation Yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: No U INA No ❑ TNA Inspected By: VaA N -S DTitle f Received By: Date: Yes JZ No ❑ YeS NO ❑ If `no' is selected, attach an accurate map to permit Yes [� No ❑ Inspected By: VaA N -S DTitle f Received By: Date: