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T 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.org/ehd PUMP INSPECTION CHECK LIST Address: A V Pe ZT00S8gJRo&�y Instion Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations GEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Q 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 ✓Z No ❑ NA ❑ _ Graded to allow drainage away from casing Yes [4 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ 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 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 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 [0 Air gap of at least 6" same as pipe diameter Yes ❑ No ❑ NA MAINTENANCE: WelVPump visible and protected from damage Yes No ❑ INA ❑ Well/Pump free from excessive vegetation Yes KZ No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If'no' 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: Inspected By: ( J(} Title: 1 tgfj Is Received By: Date: C -u n')nn Q ry � r� n � c