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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.si.gov.org/ehd PUMP INSPECTION CHECK LIST Address: Permi ction Date: — Moo E - ko /. 6 AvE m �r,CCS- MD-380-7S- 031.3118 ParameterlStandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 14; No ❑ NA❑ Casing-extends at least 12" above grade Yes H[ No ❑ NA❑ Casing extends at least 1" above pedestal Yes ❑ No [?� NA❑ C43 ih e L4L. L I-eii 4,4, 1 Free of cracks/contiguous with annular seal Yes ❑ No [A NA ❑ ►� -�� Cerne�� Graded to allow drainage away from casing Yes KZ1 No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes © No ❑ NA❑ Seal between all pipe columns and casing Yes 99, No ❑ NA❑ Sounding tubelair vents sealed properly Yes ❑ No ❑ 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 [2 No ❑ NA❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA[r MAINTENANCE: Well/Pump visible and protected from damage I Yes [ INo ❑ NA❑ Well/Pump free from excessive vegetation Yes INo ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [2 No ❑ Permit drawing sufficient to locate well in future Yes 2 No ❑ if'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes [� No ❑ OTHER: — �, ti N. nQ2Cr� Inspected By: Title: iS Received By: Date: