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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: ojyNs (� M�' o �jA Ik5 2'Lb Permit#: 00 34142 I Inspection Date: \\ / 15/ I Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x W" minimum) Yesd No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [ 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 [j No ❑ NA ❑ Seal between all pipe columns and casing Yes [J/ No ❑ NA ❑ Sounding tubelair 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 l� No ❑ NA ❑ Adequately installed check valve or BFP device Yes ff4 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes [d 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 D INo ❑ 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: rt \It'� Inspected By: ( Title: Received By: Date: