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Y 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.sigov.orq/ehd PUMP INSPECTION CHECK LIST [Received By: . I Date: Cu e>nn niaalonar 'Address: %%�� % 1� ^ / P�; mi l7 SS W7YIS G� I, L /�.�JC'/� v V 3 .. �Z 1i��$�ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations _ CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes U No E] INA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least V above pedestal Yes ©' No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [2 No ❑ NA ❑ Graded to allow drainage away from casing Yes [1 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 2 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 IYes W No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [V 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 JZ MAINTENANCE: VVe]I/Pump visible and protected from damage Yes No ❑ NA ❑ 1/VellfPump 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 permft Permit drawing sufficient to locate well in future Yes 0 No ❑ Photograph taken and attached to record Yes F17f No ❑ OTHER: - Comments: 1 I� r , � ��n, n, (,�'� Olra,c.<tvY � v 1 �► ce � r,` i%eye YI/ ► Cib I i., c :) " UAP-,(. oe Inspected By: 7iue; u s [Received By: . I Date: Cu e>nn niaalonar