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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Tefeptione: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgiehd PUMP INSPECTION CHECK LIST • Ad- dre .:..--- \ 9) 1;'-5 e- k kk c\k--eC_N.)0c-k \'`) \- •.V'<\•\kkliA (V) 3 Permit#: \c) (2105 cv-0 (6 Inspection Date: t510 13 'my\ Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) _ Yes rcj No I NA I_ _I t Casing extends at least 12" above grade Yes n No I I NA Fa - - Casing extends at least 1" above pedestal Yes n No NA Free of cracks/contiguous with annular seal Yes No) I NA n Graded to allow drainage away from casing _ Yes No n NA 17• SANITARY SEAL: - Well is sealed between pump and casing Yes K--- No 17 NA ID! Seal between all pipe columns and casing Yes , No I I NA M Sounding tube/air vents sealed properly - Yes n No I I NA 1 Chlorination port available and sealed properly Yes T No Li NA j SAMPLE TAP AND BACKFLOW PREVENTION. Non-threaded sample tap between well head and check valve or within 3' of well head Yes 0 No TI NA I'd -- Adequately installed check valve or BFP device Yes [I No n NA d No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes 17 No 4 NA E Air gap of at least 6" (same as pipe diameter) Yes n No I I NA p MAINTENANCE: . . Weil/Pump visible and protected from damage Yes No n NA Well/Pump free from excessive vegetation Yes No NA n MISCELLANEOUS: Permit drawing represents actual location of well Yesli No E If 'no' is selected, attach an accurate map to permit , Permit drawing sufficient to locate well in future Yes I No C Photograph taken and attached to record Yes li I No OTHER: . Comments: • - , V' 1041‘((k\ C"1/41 . '\ 0 0 Inspected By: \ V ‘ 1 'N' . Title: cAk V-4.)I - . - Received By: Date: n "el C