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SAKI JOAQUIN COUNTY EwIRONMEN IAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 T efep lyone;(209)468-3420 Fax: (209)468-3433 lll<°e&www.slgov.oEq/ehd PUMP INSPECTION CHECK LIST c').'dress: — —� -- — — Permit#: TT Inspection Date: 1, 5 20 Q . °t v) �b 3 'I 7�O� b 1 l ParameterlSfandard Meets SJG Standards? Comments/Measurernei-�W Recommendati011S CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Ej No ❑ 1 NA❑ 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 No ❑ NA,❑ Graded to allow drainage away from casing 1'es No ❑ NA❑ SANITARY SEAL.: Well is sealed between pump and casing Yes A No ❑ NA❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes No ❑ NA[IChlorination poll available and sealed properly `(es No ❑ NA❑ SAMPLE TAP AND BACtcl=LOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes Fj No ❑ NA ❑ - Adequately installed check valve or BFP device Yes No ❑ NA ❑ �� r No doss 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 visible and protected from damage Yes .No ❑ NA ❑ Well/Pump free from excessive vegetation Yes rj No ❑ NA ❑ MISCELLANEOUS: I Permit drawing represents actual location of well Yes No ❑ Permit drawing suff icient to locate well in future Yes F4 No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No El OTHER: VQ 1 I i Inspected By: Title: \ �1 Received By: Date: nlnA InnA C