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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 =u nonn Ad ess: o w-" 0S6 M I 'rE A' v E L�i4 I-0 P Parameter/Standard Meets SJC Standards? Perm' Inspec ion Date: w� 0 3�7 073 z/ ?,//,L- Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes D 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 E2WO[:INA Seal between all pipe columns and casing Yes V Sounding tube/air vents sealed properly Yes ❑ Chlorination port available and sealed properly Yes [ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes &Z I No ❑ INA ❑ Adequately installed check valve or BFP device Yes V No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 0 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 Yeso No ❑ If `no° is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Pj No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: &C Cc q(,L a4j s l 11.r awe C� Inspected By: o'A' '0 Title: Received By: Date: =u nonn