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r 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.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: �� 60 13 �04�U SkDly " L� tJ Inspection Date: �')� t)� 1 :1 ParameterlStandard Meets SJC Standards? ComrnentslMeasuremen / - Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ Casing extends at least 12" above grade Yes [ No ❑ NA❑ Casing extends at least 1" above pedestal Yes QX No ❑ NA❑ Free of cracks/contiguous with annular seal Yes No ❑ NA❑ Graded to allow drainage away from casing 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 ❑ 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 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: WeWump visible and protected from damage Yes No ❑ NA❑ VVell[Pump free from excessive vegetation Yes No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes EjjNo ❑ Permit drawing sufficient to locate well in future Yes f� No f`no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: b V') 'VrC p N o F r'- (I \L Inspected By: CU- �� Title: I o js - Received By: Date: cu nonn araa ron�9