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r 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 Addre 1: , 'y S C� /�,� Pe iyh�0© �� a S Ins tion �te: I c 'V•\/1 ��// Comments/Measurerr�entsl Parameter/Standard Meets SJC Standards? Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes M No ❑ NA❑ Casing extends at least I" above pedestal Yes 0 No ❑ NA❑ Free of cracks/contiguous with annular seal Yes Z No ❑ NA❑ ` Graded to allow drainage away from casing Yes W1 No ❑ NA❑ SANITARY SEAL: _ Well is sealed between pump and casing Yes M No ❑ INA❑ Seal between all pipe columns and casing Yes W No ❑ NA❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 191 Chlorination port available and sealed properly Yes W No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and 8J ..irvht�'�I'S check valA or within 3' of well head Yes ❑ No [Z NA ❑ �I Adequately insta d 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 kZ No ❑ NA❑ Well/Pump free from excessive vegetation Yes 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 Z No ❑ OTHER: Comments: Inspected By: A. Title: �}�i C Received By: Date: I' Gu_n,)nn_ 8/31/2015