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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_ov.org/ehd PUMP INSPECTION CHECK LIST Address: �/ Permit InspectiogDate: 0' - 1. / �C �U �1 0o��'s�b 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 © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [Z No ❑ NA ❑ Graded to allow drainage away from casing Yes [7 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [K 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 W No ❑ NA ❑ Adequately installed check valve or BFP device Yes [0 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 [0 MAINTENANCE: Well/Pump visible and protected from damage Yes U 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: P6wz-,- e% A4-\, Inspected By: SO Title: ( - t4;j; Received By: Date: F:u AW)n prod rnndr;