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r SAN JOAQUIN COUNTY s ENVIRONMENTAL HEALTH 'DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orcg1ehd PUMP INSPECTION CHECK LIST /gaaress: Permit#: 51b wp 0i)3870'7 Insperijon ate: ales 110 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes Qj No ❑ NA ❑ Casing extends at least 1u above pedestal Yes 4 1 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes 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 lYesEyNo ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ IN o ❑ NA Adequately installed check valve or BFP device Yes KI 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: VVe1VPump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well IYes No ❑ It `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future IYes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: U I I v S-i� I Title: Received By: . I Date: Mu Bonn nne rine 9