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i• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Address: T V ( V 1 ' q PW y� �CJ — Insp%0tio Dakie: C" U Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations GEMENT 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 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q No ❑ NA ❑ Seal between all pipe columns and casing Yes [2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [;r Chlorination port available and sealed properly IYes a No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes U 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 ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes D I No ❑ is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ lf'no' Photograph taken and attached to record Yes VI No ❑ OTHER: Comments: -- i I Inspected By: V /I 1 %�S 0 ( Title: F-1 CH Received Bv: Date: mea nOnn Qna r�na �