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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: pennit#': OZ N �c �<JK S_� �� LLQ NQS InspecfionDate: Parameter/StandardMeets SJC Standards? Comments/Measurements/ 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 T' above pedestal Yes Ej 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 No ❑ NA❑ Seal between all pipe columns and casing Yes 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 ❑ I No ❑ INA ❑� Adequately installed check valve or BFP device Yes o X INA❑ NO V No cross connections (ex: chemical feeders -- hooked to distribution system/ag flood irrigation from domestic supply) Yes 14 No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [�j MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [ No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes j 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: Y�f/IA/l /10I 1 60A-t,PL*_ TGL..L. Ij k-'O S J�-11� ptL InspectedBy: Title: Received By: Date: