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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: 3ai W - A� CA - h Po �-D Jo -6 i Perm �,1{�'ovs-nq- Inspe tion a e: M `e Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ INA ❑ Casing extends at least 12" above grade Yes [Z No ❑ NA ❑ Casing extends at least I" above pedestal Yes ❑ No ® NA ❑ Free of cracks/contiguous with annular seal Yes [� No ❑ NA ❑ Graded to allow drainage away from casing Yes SA No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing YesW/ No ❑ NA ❑ Seal between all pipe columns and casing Yes [A No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA GA 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 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 E? No ❑ NA F1Well/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 2 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Z Received By: Date: CU A-