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. r 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.org/ehd PUMP INSPECTION CHECK LIST cu AOnn ❑i" 11ne G Address: � . M �i� Si S7o�,�.'i bel ^_ ____ P1 �� 6T 3 q .2 W O Inspection Date: Parameter/Standard Meets SJC Standards? CornmentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1' above pedestal Yes ❑ No ❑ NA ❑ Q+• i'f q /7u -c Free of cracks/contiguous with annular seal Yes 12 No ❑ NA ❑ Graded to allow drainage away from casing IYes 2 No =EINA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes 5Z No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA W Chlorination port available and sealed properly I Yes JZ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes (0 No ❑ NA ElAdequately installed check valve or BFP device Yes 0 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Q Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA' MAINTENANCE: Well/Pump visible and protected from damage Yes 9 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 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:' tau,,,, re, Ins ected B p Y: a Title: Received By: Date: cu AOnn ❑i" 11ne G