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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.orq/ehd PUMP INSPECTION CHECK LIST Address: �� `- el ` �` __ I Permit#/: Inspe tion pate: N h "—j L ��^' -Shat/-7'7 /D t18 11 Parameter/Standard Meets SJC Standards? Comments/Measurements/ ReGOMmendations omments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [Z No ❑ NA❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 2 No ❑ NA ❑ Graded to allow drainage away from casing Yes EZ No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes Lj 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 I 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 V1 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 [4 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ Permit drawing sufficient to locate well in future Yes �Z No ❑ If'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: C(,t. S- Title: Adf iS Received By: Date: cu n?nn arverona r;