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SAN .JOAQUIN COUNTY Y ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.slgov.orq/ehd PUMP INSPECTION CHECK LIST Address: �� C�c�-+ CPff -P Peri : 3106PF112 _ 38 Insp tion ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes R1 No ❑ NqE01 Casing extends at least 12" above grade Yes © No ❑ N Casing extends at least 1" above pedestal Yes No ❑ N Free of cracks/contiguous with annular seal Yes No ElN Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [2 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 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 Air gap of at least 6" (same as pipe diameter) Yes ❑ jNoE1 NA ❑V MAINTENANCE: Well/Pump visible and protected from damage Yes [ No INA ❑ Well/Pump free from excessive vegetation Yes [a' 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 [o No ❑ OTHER: Comments: - Inspected By: 0" J Title: P - (4, A-sw — - Received By: Date: =u nonn arqaioneF