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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.si.gov.org/eild PUMP INSPECTION CHECK LIST Address: W94LE-9m- s -b ,J Perm � o0 8 a Inspection Pate: o Parameter/Standard Meets SJC Standards? Comments/Measuremenfs/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ INA ❑ Casing extends at least 12" above grade Yes LZ No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes E' No ❑ INAE1 Seal between all pipe columns and casing Yes1❑ No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [2/ Chlorination port available and sealed properly IYes V No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes E�? 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) I Yes ❑ jNo ❑ INA V' Air gap of at least 6" (same as pipe diameter) Yes ❑ INo, ❑ INA ❑' MAINTENANCE: Well/Pump visible and protected from damage Yes E2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [,Z 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 No ❑ OTHER: Comments: / Inspected 13y: OL AA SID Title: E14, A 5S1 J Received By: Date: