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•T i 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.orq/ehd PUMP INSPECTION CHECK LIST Address: Per i Inspection Date: D E` �.ou+s v e m 4N Eco �,,�'Poo`75 roi'4118 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing extends at least 12" above grade Yes Q No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ®P No Pf NA ❑ Cash P sw. pt) Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes Z No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q No ❑ NA ❑ _ Seal between all pipe columns and casing Yes Q No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes ® No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes W 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) Yes ❑ No ❑ NA 52 Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA [2 MAINTENANCE: Well/Pump visible and protected from damage Yes Q No ❑ NA❑ Well/Pump free from excessive vegetation Yes [a No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: C:ornrnents: C G'�S `'/' ,v�r0`a+c Inspected By: OLLt \ S0 Title: Jj i"S Received By: Date: �u n-)nn ar�ri�nr.