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` F Y 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.org/ehd PUMP INSPECTION CHECK LIST HUUI CJJ. f ; „_ r- Pe t#: _/ R58 /J / P I s rJ �� ST?) c k 10 AJ Woo 38 7 a lnspe tion,�ate: �3�((� ParameterlStandard Meets SJC Standards? IE Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ N.A. ❑ Casing extends at least 12" above grade Yes 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 V No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing 1yes WWNAE01 Seal between all pipe columns and casing Yes ©Sounding tubelair vents sealed properly Yes ❑Chlorination port available and sealed properly Yes 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 system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [Z Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA ►� MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes W 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 2 No ❑ OTHER: Comments: N 0 S44Uf l h� -�a P Inspected By: Yat- S�') I Title: H . Ass / S fes, f I Received Cu A Dnn nnfionec