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y/-41Y V VH1e(V 1111 vv UIV I 1 ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 96205-6232 Telephone; (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Address: Pe tt_ 1 x'30 /J• Pqtfusot, Pwk S-fvcLh,-h Wr 38sM11ris p16VII?e: Parameter/Standard Meets SJC Standards? C om m ents/M eas u rem en ts/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA❑ Casing extends at least 12" above grade Yes Fl No ❑ NA❑ Casing extends at least V above pedestal Yes © No ❑ NA❑ Free of cracks/contiguous with annular seal Yes 9--No ❑ NA❑ Graded to allow drainage away from casing Yes © 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 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 No ❑ INA❑ ; Adequately installed check valve or BFP device Yes No ❑ INA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ INA M Air gap of at least 6" (same as pipe diameter) Yes ❑ Noff NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA❑ VVell/Pump free from excessive vegetation Yes No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ Permit drawing sufficient to locate well in future Yes No ❑ if`no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes [+�] No ❑ OTHER: Comments: Inspected By; S- Title: A /f'7�14I/ Received By: Date: =LJ nonn nia1�n �