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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.org/ehd PUMP INSPECTION CHECK LIST AdTs: P 04qq S. OS�i- !/'J TF'41 .lt00 ? l i� `f 1e Parameter/Standard I Meets SJC Standards? I Comments/Measurementsl Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4n minimum) Yes No❑ NA ❑ No ❑ Casing extends at least 12" above grade Yes [,� No ❑ NA ❑ No ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ No ❑ Free of cracks/contiguous with -annular seal Yes No ❑ NA ❑ No ❑ Graded to- allow drainage away from casing Yes [a No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes © No ❑ NA ❑ - Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 9 Permit drawing represents actual location of well Chlorination wort available and sealed nrnnPrly YPz Imo' Nin n niA F-1 Permit drawing sufficient to locate well in future SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 12 No ❑ NA ❑ Adequately installed check valve or BFP device Yes V 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 [v]' _ MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from. excessive vegetation Yes Rf No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes P 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 j]✓ No ❑ OTHER: Comments: j Inspected By: CO J J Title:�J ' j. C Received By: Date: