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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:www.sjgov.org/ehd _ PUMP INSPECTION CHECK LIST Address: � PWermiOU3 � Ir a60.0�� NTt�� 7gvc�on te: 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 L7 No ❑ NA ❑ Casing extends at least 1" above pedestal YegLZ No ❑ NA❑ Free of cracks/contiguous with annular seal Yes 12 No ❑ NA ❑ Graded to allow drainage away from casing Yes ,j No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes Ftl No ❑ NA ❑ Sounding tubefair vents sealed properly Yes f;Z 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 ❑ NA ❑ Adequately installed check valve or BFP device Yes VI No ❑ NA❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation rom domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 2 MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA❑ Well/Pump free from excessive vegetation Yes 0 No ❑ INA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ Permit drawing sufficient to locate well in future Yes Q No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ _ OTHER: Comments: It L-41,�,�� Inspected By: f r l -- - --- — Title: Received By: Date: cu n)nn Qrai�na{