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. 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 j I Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; www.sidov.org/ehd PUMP INSPECTION CHECK LIST l FAddress:2 �� , �, f-igr Cn, Gel; • Perm* V,/n 5(�t n W Do Inspe'tion I zl Parameter/Standard NA ❑ Meets 5JC Standards? Comments/Measurements) Recommendations CEMENT PEDESTAL: NA ❑ Air gap of at least 6" (same as pipe diameter) Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ NA ❑ Casing extends at least 12" above grade Yes K No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Yes Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Graded to allow drainage away from casing Yes No ❑ NA ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Permit drawing sufficient to locate well in future Sounding tube/air vents sealed properly Yes No ❑ NA ❑ YesN Chlorination port available and sealed properly Yes t99 No ❑ NA ❑ SAMPLE TAP AND DACKFI nw RRFA/FnIT1nh1. Comments: Non -threaded sample flap between well head and check valve or within 3' of well head Yes No ' NA ❑ 4W--4- -3/Lf Adequately installed check valve or BFP device Yes A 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 ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ❑ No ❑ No ❑ lf'no' is selected, attach an accurate map to permit No ❑ Permit drawing sufficient to locate well in future Yes ❑ Photograph taken and attached to record YesN OTHER.: Comments: - A `03 75� q1 Awo V- "V\ w a l`Q(e 64"', Inspected By: U V Title: g r Received By: /p �/ Date: Gu A -)nn