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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.orq/ehd PUMP INSPECTION CHECK 11ST Cu n)nn Address:qg 41 n I WE Pb S� G k_ � � Y Perm' b W 003-7 ,.� Ins ction ate: to �� l Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [2 No ❑ INA ❑ Casing extends at least 12" above grade Yes © 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 U No ❑ NA ❑ Seal between all pipe columns and casing Yes V No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Z Chlorination port available and sealed properly Yes ❑ No ❑ NA i❑/ 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 [2 No ❑ NA ❑ pri r wvi c�i�� No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I Yes ❑ INo ❑ INA Air gap of at least 6" (same as pipe diameter) Yes JZ I No ❑ I NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes V 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 [0 No ❑ OTHER: Comments: Inspected By: vp0, Title: rb Az' Received By: Date: Cu n)nn