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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.oVehd PUMP INSPECTION CHECK LIST Address 1 S� a - k u P) t( t,,� 4c." PO Pe W� 0 0 31303 insp coon Date: I z q11,7 ParameterlStandard 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 [' No ❑ INAD Casing extends at least V above pedestal Yes [V 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 &n No ❑ INA ❑ Seal between all pipe columns and casing Yes ;Z No ❑ INA ❑ Sounding tube/air 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 No ❑ NA ❑ ; Adequately installed check valve or BFP device Yes SK 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 V MAINTENANCE: Well/Pump visible and protected from damage YesNo E]NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No Permit drawing sufficient to locate well in future Yes U No Photograph taken and attached to record Yes 54 No OTHER: Comments: If 'no' is selected, attach an accurate map to permit mspecrea try: Title: —o f'F . C-tJt 414% Received By: Date: Mu n')nn