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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.sigov.om/ehd PUMP INSPECTION CHECK LIST Address: It -752 5 2 E n T -' y� C P� PJp� y �� d�. Insp1qWV ate: j� F-r K V � Z Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [a No ❑ NA❑ Casing extends at least 12" above grade Yes [I No ❑ NA❑ _ Casing extends at least 1° above pedestal Yes [2 No ❑ NA❑ Free of cracks/contiguous 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 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 IYes ❑ 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[� 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 91 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: kla,4, Title: - 4- Sj aht Received By: Date: �u n)nn oionnn c