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ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeJton Avenue, Stockton, CA 95208-6232 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slgov.om/ehd PUMP INSPECTION CHECK LIST Address: I PeriniInspe tion Date: �.to AJ i�� -�� 7V C kI IBJ oo38� d7 /T037 Com m en Parameter/Standard Melts SJG Standards? ts/M eas u rem entsl Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA❑ C{'au,"J Casing extends at least 12" above grade Yes ❑ No ❑ NA❑ Casing extends at least 1" above pedestal Yes ❑ No ❑ NA❑ Free of crackstcontiguous 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 V No ❑ NA❑ Seal between all pipe columns and casing Yes W No ❑ INA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA V _ 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 0 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAV MAINTENANCE: V1/elVPump visible and protected from damage Yes 2 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: Comments: r cz !� L ly�.Z.c T l.�1. Sit G[c'S �,J t! 4-ex nspected By: s "title14 � deceived By: Date: cu n�nn