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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 Address: 4.1 r jock-cow 11 Ii T� Insp tion Date: r Parameter/Standard Meets SJC Standards? Comments/Measurements/ F7 Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [✓1 No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes [9 No ❑ NA ❑ SANITARY SEAL: E:u n9nn orad ron-i c Well is sealed between pump and casing Yes ['o No ❑ INA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Ye No ❑ NA [r Chlorination port available and sealed properly IYes ❑ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes &A No ❑ NA El Adequately installed check valve or BFP device Yes V No ❑ INA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) lYes ❑ No ❑ NA Ol Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes 6Z No ❑ NA ❑ WelllPump free from excessive vegetation Yes V No ❑ INA ❑ 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 No ❑ OTHER: Comments: Inspected By: Q S Title: &V I revs r►rL( +':� Received By: Date: E:u n9nn orad ron-i c