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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.siciov.org/ehd PUMP INSPECTION CHECK LIST Address:Permit#: COnr�C-2 �D S� � � P 0 03 7 a 6 Insp ction ate: 01 o1 Parameter/Standard --T-Meets SJC Standards? Commenfs/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes [9 No ❑ NA ❑ Casing extends at least 12" above grade Yes ® 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 IYes 9 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [+1 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 EO No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I Yes ❑ No ❑ NA _ Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA Q MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA ❑ Well/Pump free from excessive vegetation Yes VI 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 V1 No ❑ OTHER: Comments: M�, .e.� a 0' cx�5j , o �- P �. -`- 0 s .rte �� P N G Gr- ((.tk vwnw W" Inspected By: L U` SJ Title: "Zi Received By: Date: