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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, GA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: � LL -7 P5iI�-7J Insp� O 06 MeetSJC Standards? CommentslMeasurements/Parameter/standard Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ 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 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Fil No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tubefair vents sealed properly Yes ❑ No ❑ NA EV Chlorination port available and sealed properly 1 Yes Q- No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 2 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 EV MAINTENANCE: VVe]VPump visible and protected from damage Yes No ❑ Well/Pump free from excessive vegetation Yes +ENA No ❑ 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: - r 1fwicbdV� C) -r_le ., tJ Cm a�) Inspected By: a"A" Title. - Received By: Date: =u n-Dnn nxieionag