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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.sigov.orq/ehd _ PUMP INSPECTION CHECK LIST Address: 1Q S CD R�A �. tIULIp r<,/ A Cy Pet IT 389 2a i/70 IVon t's te: ParameterlStandard Meets SJC Standards? h1 CommentslMeasurementsl Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ _ Casing extends at least 12" above grade Yes b2 No ❑ NA❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes [� No ❑ NA❑ SANITARY SEAL: -- -- Well is sealed between pump and casing Yes U No ❑ NA❑ Seal between all pipe columns and casing Yes k2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 2 Chlorination port available and sealed properly Yes 4Z 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 [v?" 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 ® 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: G,,ornment/ inspected BI : _ S O Title: E - 14• ASI .l Received By: Date: =u nonn ar�ti�nar.