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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.sjgov.orq/ehd _ PUMP INSPECTION CHECK LIST P:cldress: Permit#: Inspection Date: W- " 0.5 w Q 0b3� 31 J(3 b-\ -) ParameterlStandard [Uieets SJC Standards? CoirRecornmenda iorlsnts/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes INo ❑ NA❑ Casing extends at least 12" above grade Yes D INO ❑ NA❑ Casing extends at least T' 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❑ j Seal between all pipe columns and casing Yes No ❑ NA❑ Sounding tube/air vents sealed properly - Yes [,,'r No ❑ NA❑ Chlorination port available and sealed properly Yes ❑ No [j NA❑ ML�Q-�, Q Q-t� SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No 4 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 1� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[v� MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA❑ Well/Purnp 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 No ❑ OTHER: Comments: --- F► �N 4� N o f��`?�0�� `�(a M� I,TNv, t�A Inspected By: _ _ Title: Received By: _ Date: