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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.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address:Per k' bT 'j 1/\/ 0-'J CT M / r � 6� #: t�J F" 3 3 .24 Inspection Date: o 4 /o,,z /iY _ Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [v]� No ❑ NA ❑ Casing extends at least 12" above grade Yes Q No [v] NA ❑ Casing extends at least 1" above pedestal Yes ❑ No Q NA ❑ Free of cracks/contiguous with annular seal Yes LZ No ❑ NA ❑ Graded to allow drainage away from casing Yes 2 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 17 Chlorination port available and sealed properly Yes La No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head YesE0 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 ❑ Well/Pump free from excessive vegetation Yes 2 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ lf'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: cQ,,�, Inspected By: 5' Title: Received By: Date: CU A)nn Q/111I ner