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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 ELI n0nn ona rine c Address: _ —1S k41.S �U E 's ,�G � /b� P OC)03-�Iol c ionDate: Act 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 [ No ❑ NA ❑ Casing extends at least V above pedestal Yes 0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [;d No ❑ NA ❑ Graded to allow drainage away from casing Yes © No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes FJ No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Ye No ❑ NA [r Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AND EACKI=LOW 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 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 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 [A No ❑ OTHER: Comments: Inspected By: -rJso ITitle: V r,Dna� �QA�j r�SJ Received By: I Date: ELI n0nn ona rine c