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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.orq/ehd PUMP INSPECTION CHECK LIST Permilnspe cf, q S ` JA -CIC CIC / V AC- S -1 -DC I VG Woo 3 )oo-6 tion Date; l Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendafiions CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ - Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes []' No ❑ NA ❑ Free of crackslcontiguous with -annular seal Yes ® No ❑ NA ❑ Graded to -allow drainage away from casing Yes �Z No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing IYes [V INo ❑ NA ❑ - Seal between all pipe columns and casing Yes [jj No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [5 Chlorination port available and sealed properly Yes ❑ No ❑ NA O SAMPLE TAP AND BAGKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ 'MNoE1 NA R1 Adequately installed check valve or BFP device Yes Q'NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA W MAINTENANCE' Well/Pump visible and protected from damage Yes Well/Pump free from. excessive vegetation Yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: No U INA No ❑ INA Yes V No ❑ Yes ©' NO ❑ ff `no' is selected, attach an accurate map to permit Yes No I -I Inspected By: Title:' Received By: Date: