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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.s(gov.orq/ehd PUMP INSPECTION CHECK LIST Address: ,. 5 i C �-� M 4-� C4 PermitIns ction Date: � m 3,81 its Parameter/Standard Meets SJC Standards? Com ments/Measu rementslRecommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Rt No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least V above pedestal Yes © No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes E2 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 ❑ NAS 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 ❑ (,a 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 ❑ Co lel,+.. MAINTENANCE: -j-Z Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes R� 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 1p] No ❑ Photograph taken and attached to record Yes [� No ❑ OTHER: Comments: 60 orl C'� "i t4+ Inspected By: a --j' Q Title: A-Jst j Received By: Date: cu n)nn ArogiI)nq�