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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:wvvw.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Insp do Date: ° rte j vc, ,J Ko a � 9� t�; �I , Parameter/Standard Meets SJC Standards? Com ments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Q' No ❑ NA ❑ Casing extends at least 12" above grade Yes k" No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 2r No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes V No ❑ NA ❑ Graded to allow drainage away from casing Yes Bd No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes [/r 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 ❑ NA ❑ Adequately installed check valve or BFP device Yes 5d No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [� Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [� MAINTENANCE: Well/Pump visible and protected from damage Yes 2, No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 2f 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 fir .r'!�ctograph taken and attached to record Yes [r No ❑ OTHER: Comment�N � �L rJ o Inspected By: Title:Ei VI1'bY1 ' I+e�� S► Received By: Date: EH-4200-