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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.org/ehd PUMP INSPECTION CHECK LIST Address:, I L,LL C /" R. /� f)7*P0 PW �#: Inspection ,� iJ00- Date: /z/�6ji. Parameter/Standard Meets SJC Standards? Comments/Meas urements/16 Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ Casing extends at least V above pedestal Yes ❑ Na ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA ❑ Lc 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 0 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [? 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 V NA ❑ 0 �/ Adequately installed check valve or BFP device Yes L' 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 Y MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: j rj 0 IV 0 C� w�9�, -0 Ca.C, -Ct� L h W tld- � Inspected By: a J Title: Received By: Date: