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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 l=ax: (209)468-3433 Web:wwvd.sigov.or /q ehd PUMP INSPECTION CHECK LIST Address'5541 Per it#: Insp ctio�� ate: ,j 5 1 /J - So LA-R I R N 9,bC , S_lb _06� S� D A00-77 �l. r� Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: --- I Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least V above pedestal Yes E2 No ❑ NA❑ Free of cracks/contiguous with annular seal Yes W No ❑ NA❑ Graded to allow drainage away from casing I Yes [✓] No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes []" No ❑ INA❑ Seal between all pipe columns and casing Yes D No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Z 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 No ❑ NA ❑ Adequately installed check valve or BFP device Yes W No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation I rom domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes ®_No ❑ NA❑ Well/Pump free from excessive vegetation Yes O No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map fo permit Photograph taken and attached to record Yes Q No ❑ OTHER: Gomments: — /��J rr � �.c2 m�Mf l.G�l t►� � .,Y„/,�,.v., �I n� i..��-� hRR� ti'1�� `�. IBX l hS �-QC I i B : Inspected P Y A.4 1 -----___..------------ -- --- Title: r�J31J 'r�iat , Received By: Date: cu n,)nn arxionar_