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SAN JOAQUIN GOUNTY 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 Address: /�Pe�nrb. API ^ � lns ec5 Da>e: 1� I vIE OO� P�� -78 6s- ��3! / Parameter/Standard Meets 5JC SEand d ? Comments/Measuremenfisl GEMENT PEDESTAL: Recommendations Dimensions of surface seal 2'x2'x4u minimum) Yes © No ❑ NA ❑ Casing extends at Ieast 12" above grade Yes ® No ❑ NA ❑ Casing extends at Ieast T' above pedestal Yes No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes [a 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 tubelair vents sealed properly Yes Q No ❑ NA ❑ Chlorination port available and sealed properly Yes 0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and S �p check valve or within 3' of well head Yes ❑ No U NA ❑ f V Adequately installed check valve or BFP device Yes &I No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply Yes ❑ No El NA F� Air gap of at least 6" (same as pipe diameter) Yes ❑ No [INA MAINTENANCE: Well/Pump visible and protected from damage YesQ1 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [4 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If 'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER= Comments: lnspectec Received Mu A -nn Title: Date: