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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: 1353_0 IN , i4'Jd Z/ uod - V Permit#: / WPOO 1925Oy Inspection Date: -7—/L21fa Parameter/Standard Meets SJC Standards? Comments/Meas urements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes ©' No ❑ NA ❑ Casing extends at least 12" above grade Yes [3' No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑''r No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Y No ❑ NA ❑ Seal between all pipe columns and casing Yes F� No ❑ NA ❑ Sound;^ng tube/air vents sealed properly Yes ❑v' No ❑ NA ❑ Chlorination port available and sealed properly Yes [V No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head y Yes Z No ❑ NA ❑ Adequately installed check valve or BFP device Yes 2" No ❑ NA ❑ No cross 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 IM MAINTENANCE: Well/Pump visible and protected from damage Yes Q No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ 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: Inspected By: &i? v Title: twsY i s Received By: Date: cu n)nn P1gg1')n4F