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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95206-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd PUMP INSPECTION CHECK LIST Address:' 0 W 4 1 TCPermi L!J siacici7�,� W&038 5--b3 Inspe tion ate: /o Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes Q No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 2 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [j� No ❑ NA ❑ Seal between all pipe columns and casing Yes U No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA V Chlorination port available and sealed properly lYes Fz' No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [j'' No ❑ NA ❑ Adequately installed check valve or BFP device Yes [Vr No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA E2 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump 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 0 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: t k_Z�ISIVCJ-�, Ce".f Cc, C eA k,-" Ct"U, kuv Inspected B ok S Title: r ' ASS 1S q- Received By: Date: r-L-1n')nn anai,)nIr