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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.orcl/ehd PUMP INSPECTION CHECK LIST Address oco,� � �� Per it#: Insp ctio Date: W /"6 V e,�,.) �Tra L IBJ o 36 8 4 1 x�a0 tl Parameter[Standard I Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ uAa> 04- LQ►Cr� Casing extends at least 1" above pedestal Yes ❑ No ❑ NA ❑u �� d,;, Free of cracks/contiguous with annular seal Yes ❑ No F]NA ❑ Yes ❑ Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ Yes ❑ I SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ NA ❑ Seal between all pipe columns and casing Yes W1 No ❑ NA ❑ NA ❑ Soundina tube/air vents SPalPrl nrnnPrly va,z 1-1 Nln n Nio F-.7 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 &Z 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 ❑ I No ❑ NA 12 MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Z 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: 1v9 (Xrntw� C41-01� Sarrl`tlos wGl( l�-es �C Inspected By: rj Title: Received By: Date: EZu n)nn