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Y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax; (209) 468-3433 Web: www.sigov.or /q ehd PUMP INSPECTION CHECK LIST cu A0nn tt /Q a lo n -t c Address: �SLP�w�4�� o � `�$Z Permit#: Inspection Date: vJQ "0°-j 3 L 0B 7�11 ParameterlStandard Meets SJC Standards? Comments/Measurementsl Recommendations CEMENT PEDESTAL; Dimensions of surface seal (2'x2'x4" minimum) YesWNoo ❑ Casing extends at least 12" above grade Yes❑ Casing extends at least I" above pedestal Yes❑ Free of cracks/contiguous with annular seal Yes ❑ Graded to allow drainage away from casing Yes EJ No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ,/ NoEl NA ❑ Seal between all pipe columns and casing Yes [X No ❑ NA ❑ Sounding tubetair vents sealed properly Yes 19 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 14 Adequately installed check valve or BFP device Yes [J No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes d No ❑ NA ❑ Air gap of at Ieast 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 IYes No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Nc ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: - 10,0- ` t2 C �t.Q—WiN� QU�� Q S1l�t k,VONJsV 'O Inspected By: A Title: ' I Received By: Date: cu A0nn tt /Q a lo n -t c