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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 Gu AOnn Qua i1ma G Address: E 5T_ E F l o Lk T AJ Perm' #: w Qo -7� 3 9 Insp ction ate: a s 1. Parameter/Standard Meets SJC Standards? Comments/Measurements! Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes W NO ❑ INAD Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ Graded to allow drainage away from casing Yes 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 [� Chlorination port available and sealed properly I 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 6Z Adequately installed check valve or BFP device Yes 16 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 LZNo ❑ 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 [Z No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: VamS Q Title:61 U iQA ( tfkcit� Afj Received By: Date: Gu AOnn Qua i1ma G