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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.s►clov.org/ehd PUMP INSPECTION CHECK LIST Addre ynspt� r - AAC I SSU.S W�y (SCA Lo/J Pwr"3$ / 1!t) 1.��1 ate: Parameter/Standard Meets sic Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [2 No ❑ NA❑ Casing extends at least 12" above grade Yes Q' No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA❑ Free of cracks/contiguous with annular seal Yes R1 No ❑ NA ❑ Graded to allow drainage away from casing Yes [a 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❑ Chlorination port available and sealed properly lYes 9 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 Q( 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[✓7 MAINTENANCE: Well/Pump visible and protected from damage Yes 2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Vj 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: Inspected By: Title: �' 14 A--Uts Received By: Date: 1=u n)nn n�a imine G