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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: o tt 4 �/KLI � t-rc A LC) Aj Permit w p o o 38 3 �Z Inspect' ate: o 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 0 No ❑ NA [—I Casing extends at least 1" above pedestal _YesV No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes L?] No ❑ NA ❑ Graded to allow drainage away from casing Yes [A No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ INA ❑ 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 [j 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 ❑ 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 1�2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [2' No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ if ono' 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 No ❑ OTHER: Comments: f Inspected By: Gtti. Title: ) If Received By: Date: C:u n)nn ❑/oai1)naG