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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.sictov.orq/ehd PUMP INSPECTION CHECK LIST Address: b 20 . �� 5 ) � �� S-ZHo Permit#: ' 00-A A_S Inspection Date: I M o l It Parameter/Standard Meets SJC Standards? Com ments/MeasurementslRecommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ INA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes J. 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 E] No E] ,/ NA [/f 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 Ej 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 d No ❑ OTHER: Comments: MA �},S't � w �- L.o c. � � � 9 � � � p s� � R Q � F F (, t✓�N � {� 0 Inspected By: dv 9 L n\�J" \ Title: Received By: Date: