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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868_East_Hazelton_Av-enue,_atQ-cktQ.n, CA 95205-6232 - Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.org/ehd - -PUMP INSPECTf®WGIFIECKLIST-- Address:Permi :S,qoo E( Kz /�fpe&4, LI J /toff W ro 3 6 6 Inspe tion Date, Parameter/Standard _T Meets SJC Standards? Connnients/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing extends at least 12" above grade Yes 2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 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 D No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes 2 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes No ❑ INAF] Adequately installed check valve or BFP device Yes L4 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 MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA 0 MISCELLANEOUS: Permit drawing represents actual location of well Yes U1 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: s `� Title: Received By: Date: nMA tlf Aa