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r 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 L.I,�T Address* Perms : 7nspctioe I-OOMI.S F� STOCk1b .1� ov3814Z —04113-T '- Parameter/Standard Meets SJC Standards? CommentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of'surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing-extends at least 12" above grade Yes ❑v. No ❑ NA❑ Casing extends at least 1" above pedestal Yes E� No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA❑ 64.1"x. Graded to allow drainage away from casing Yes ❑ No NA ❑ AP-�— SANITARY SEAL: Well is sealed between pump and casing Yes [q No ❑ NA ❑ Seal between all pipe columns and casing Yes ❑ No ❑ NA❑• Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 5J Chlorination port available and sealed properly Yes 0/ No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes Q 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) Yes ❑ No ❑ NA[9 MAINTENANCE: Well/Pump visible and protected from damage Yes ❑✓ No ❑ NA❑ Well/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: � SW Yy-o-I.v.o�-�. Inspected By: OLAA S >J Title: %J , Received By: Date: