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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.oLq/ehd PUMP INSPECTION CHECK LIST Address: / Per t#: Insp ctio Date: 5 -ST. A)VT A 'rK A G y 2WD3C�a 3 10110311Y Parameter/Standard =eetsJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [g No ❑ NA E]Casing extends at least 12" above grade Yes ® No F] NA❑ _ Casing extends at least 1" above pedestal Yes [A No ❑ NA❑ Free of cracks/contiguous with annular seal Yes W No ❑ NA❑ Graded to allow drainage away from casing Yes M No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes W1 No ❑ INA❑ Seal between all pipe columns and casing Yes JA No ❑ NA❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA[/9 Chlorination port available and sealed properly IYes V No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and /`,,s4-;//.e J no check valve or within 3' of wellhead Yes ❑ No 0 NA❑ W,A 3 , z,f w.eit 44 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[7� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[� MAINTENANCE: Well/Pump visible and protected from damage Yes &I No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes g 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 [A No ❑ OTHER: Comments: ?S ,1,,l W, ' c„� "mm 3 rb Inspected By: O.A^ SD Title: F AJS%J 44h — Received By: Date: .. , AfIA fnnAG