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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: I 1 1. - CU Gt,j � Al PO/J Perm! w o � 7llipllooll.4- InsctiDate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Ej No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [Z No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes U No ❑ NA ❑ Seal between all pipe columns and casing Yes M No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [f Chlorination port available and sealed properly 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 ❑ 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 M Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes V No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ lf'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 [A No ❑ OTHER: Comments: / Inspected By: .S� Title: Received By: Date: