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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:wwvd.sigov.orq/ehd PUMP WSPECT'ION CHECK LIST _ Address: — -- Permit=:: --- Insp�tlon Date: Parameter[Standard Meets SJC Standards? CommentsIMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" rninirnum) Yes ® No ❑ NA❑ Casing extends at least 12" above grade Yes © No ❑ NA❑ Casing extends at least 1" above pedestal Yes [Z No ❑ 1 NA❑ Free of crackslcontiguous with annular seal Yes © No ❑ NA❑ Graded to allow drainage away from casing Yes V] No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q No ❑ INA ❑ Seal between all pipe columns and casing Yes [;�r No ❑ INA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ INA [� Chlorination port available and sealed properly Yes U No ❑ INA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes 21 NO ❑ INA ❑ 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 W Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAM MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA❑ Well/Pump free from excessive vegetation Yes 2 No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ Permit drawing sufficient to [orate well in future Yes No ❑ lf'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: �-�� Comments: �+ �CC i Inspected By: Y" 1S(� — ----- --- -- Title: ( gJJ1J �h� Received By: Date: cu A)nn tona r_