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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.sjgov.om1ehd PUMP INSPECTION CHECK LIST Address: 0 a/ G a i w n k Ll �j r-} dC. A I Per i �� 3� 6ri lns e tion ate: �a Parameter/Standard Meets SJC Standards? Comments/Measurementsl Recommendations � CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes [ No ❑ INAD Casing extends at least 12" above grade Yes [a I No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of crackslcontiguous 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 I Yes ® JNoEl I NA ❑ - Seal between all pipe columns and casing Yes ® No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [V Chlorination port available and sealed properly Yes Q No ❑ NAD- A❑SAMPLE SAMPLETAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes JZ No ❑ NA ❑ Adequately installed check valve or BFP device Yes Q( No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA )Z Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAV MAINTENANCE: Well/Pump visible and protected from damage Yes EV No ❑ NA ❑ Well/Pump free fromexcessive vegetation Yes VF No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [!" No ❑ lf'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [0 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: / Inspected By: CAJ 0 Title:1XV9 rbAfYVA[Qt�' Received By: Date: