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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 =u n')nn 01�4l1n4c .. Address:l� ,O� � c E - m � �-JS [- Perrpo O �i • w 1 Inspection ate: b has i Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [] No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ 1 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 [0 No ❑ NA ❑ Seal between all pipe columns and casing Yes M No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA I Chlorination port available and sealed properly Yes EJ 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 ❑ J4-,wf4r � Q 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 M MAINTENANCE: Well/Pump visible and protected from damage Yes v❑ INo ❑ INA ❑ Well/Pump free from excessive vegetation Yes © I 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 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: You, J � Title: 111rprr�� a1 QKiiz .1J Received By: Date: =u n')nn 01�4l1n4c