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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.sigov.orq/ehd PUMP INSPECTION CHECK LIST Address: , r J +v A L P � If � PSK• 0 ©� � � d SInspe/3/n ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) YesNo ❑ NA ❑ Casing extends at least 12" above grade tYes No ❑ NA ❑ Casing extends at least V above pedestal No ❑ NA ❑ Free of cracks/contiguous with annular seal� No ❑ NA❑Graded to allow rlrainanaa�niav from cacinnE n1 I—1 nin r—1 - SANITARY SEAL: u Well is sealed between pump and casing Yes 0 No ❑ NA ❑ Seal between all pipe columns and casing Yes V No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA SZ 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 M Adequately installed check valve or BFP device Yes Ej 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 Q MAINTENANCE: Well/Pump visible and protected from damage Yes Q No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes EX No ❑ OTHER: Comments: Inspected By: �lLin S Title: Jdl a,4 Received By: Date: r -u A )r)n 010410n4=