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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/ehd PUMP INSPECTION CHECK LIST Address: caa h . Jl 4 -r- Aj F_ 2j iz, r..j Permit#: WrOCZILYA Inspection Date: Parameter/Standard Meets SJC Standards? Comments Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ Casing extends at least V 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 ❑ 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 ❑ No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes❑ No ❑ NA E]Well/Pump free from excessive vegetation Yes El 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: /�94T 616^411u G Aj to �� T .57 Inspected By: kl'oAj6— Title: Received By: Date: EH -4200- .9/31 nn 15