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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9868 East Hazelton Avenue-, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.oLq/ehd PUMP INSPECTION CHECK LIST Address: 10214 F W A-� Lp �-b STO �o PerIf (70,f15-4 inspe tion ate: 1q9 ' 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 Q No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes '2 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [] No ❑ NA ❑ Seal between all pipe columns and casing Yes U No ❑ NA ❑ Sounding tube/afr vents sealed properly Yes ❑ No ❑ NA [2' Chlorination port available and sealed properly Yes V No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 0 No ❑ NA ❑ Adequately installed check valve or BFP device Yes U No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No I NA Air gap of at least 6" (same as pipe diameter) jYesE1 No ❑ NA [1]� MAINTENANCE: Well/Pump visible and protected from damage Yes L2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 9 No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes 0 No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 2,No ❑ Photograph taken and attached to record Yes No ❑ OTHER: — Comm ts: � L2J�c.- Inspected By: Gi.�-� S L Title: � - H - AD, f �A u Received By: Date: