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SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 1 efephone:(209)468-3420 Fax. (209)468-3433 Web:www.sigov.org1ehd PUMP INSPECTION CHECK LISA' _ P:ddress:- Permiti':� Tlnsp ction Date: AAAA . �-` � o�.��o��. a5 tip_ �.o �o�� 3 kA Parameter/Standard Meets SJC standards? Coi,,rients/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'xA" minimum) Yes I No ❑ INAR 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 sealYes No El ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ f�= SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA❑ Seal between all pipe columns and casing Yes [j No ❑ NA❑ Sounding tubelair vents sealed properly - Yes [j No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No [:] ,NA SAMPLE 'rAP AND BACKFLOW PREVENTION: Iwon-threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [� Adequately installed check valve or BFP device IYesg No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No [ NA❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ jNoE1 NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation1'es No ❑ NA ❑ I MISCELLANEOUS: I 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: I i Inspected By: Title: Received By: Date: