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%jt-uV VlJrib;V 11Y -,V u1V1 1 ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.om/ehd PUMP INSPECTION CHECK LIST Address: -�^� Nis 0 n e J C A� to J )'ermit�#: J K.�I-% N do "�77 7 3 lnsp ction Date: � to 31 Parameter/Standard Meets SJC Standards? Comments/Measurements] omm ents/Measurements/Recommendations Recommendations CEMENT PEDESTAL: Dimensions of surface sea] (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at Ieast 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1" 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 1Y No ❑ NA ❑ Seal between all pipe columns and casing Yes g No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA ❑9 Chlorination port available and sealed properly Yes V 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: VVe11/Pump visible and protected from damage Yes V No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Z No ❑ NA ❑ _ 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: P Inspected By: 0.4. r,3so Title Received By: Date: CLI nonn