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L + S 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.org/ehd PUMP INSPECTION CHECK LIST Address: PS P_D O_7S 9'f3 Inspection I te: Paras Teter/`Standard ' Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ INA ❑ Casing-extends at least 12" above grade Yes No ❑ NA❑ Casing extends at least V above pedestal Yes No ❑ NA❑ Free of cracks/contiguous with annular seal Yes P No ❑ NA❑ Graded to allow drainage away from casing Yes [0 No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes J0 No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/afr vents sealed properly Yes ❑ No ❑ NA 5 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 Q( No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I Yes ❑ No ❑ NA 51 Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA Q MAINTENANCE: Well/Pump visible and protected from damage Yes EY INo ❑ INA❑ Well/Pump free from excessive vegetation Yes [�r I No ❑ I 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: jCtX/,9 ` dy �C tom. u �n �( .0�l lY:�i4��'V.^^vT (iN'^.^r NU /'•� ��-q(�\vim / V W M �I.L1.1) � � �)�OM J )U Ins ecce I By: V RM k rJ SSU Title: E ' �-� • ,�SSRS 171— , Received By: Date: