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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgtehd PUMP INSPECTION CHECK LIST Address: rO oo _ J VERONICA, 61 Gk� Perm*O 0 3 6 q s_7_ In g speciion Date: Parameter/Standard Meets SJG standards? Gomments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes© No ❑ NA ❑ Casing extends at least 12" above grade Yes W No ❑ NA ❑ Casing extends at least 9" above pedestal Yes [0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes [Vj No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing YeFVNoOEE] Seal between all pipe columns and casing Ye kO Sounding tube/air vents sealed properly Ye Chlorination port available and sealed properly Ye SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes V No ❑ NA ❑ Adequately installed check valve or BFP device No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic sup Iy) Yes No ❑ NA ❑ Yes ❑ No ❑ NA Air gap of at Ieast 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damageYes ]Yes j�' No ❑ NA ❑ Well/Pump free from excessive vegetation No r-1 NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well P Yes (V No ❑ erlTlrt drawing sufficient to locate well in future Yes N0 ❑ lf'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes ru No I—( OTHER: I�.vinrnen�s: nspected By: �` Q�t.� I V S O Title: teceived By: Date: =u .conn 11 VIV t.