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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web; www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Huulcaa. / 0 i AA 11h �r WelVPump visible and protected from damage Yes Pe i '070c)3-7633 070 o 3-76 33 Inspection Date- ate: / ParameterlStandard Meets SJC Standards? Yes Com ecom M naso ments! Recommendations CEMENT PEDESTAL: MISCELLANEOUS: Permit drawing represents actual location of well Yes Ld Dimensions of surFace seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ - Casing extends at least 12" above grade Yes 1Z No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0 No ❑ NA ❑ Free of crackslcontiguous with -annular seal Yes © No ❑ NA ❑ Graded to -allow drainage away from casing NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes RZ ❑ - Seal between all pipe columns and casing Yes jV WEE0j] ❑ Sounding tubelair vents sealed properly Yes ❑ Chlorination port available and sealed properly Yes M❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ Nor 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: WelVPump 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 Ld No ❑ if `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Ljq No ❑ —Yes Photograph taken and attached to record Yes © No ❑ OTHER: Comments: M.. J'P�"'� Inspected By: NS Received By: C. Title: ` H 4jj 4 Date: