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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.orq/ehd PUMP INSPECTION CHECK LIST Address: // q-4,0 C ' M I L %hN NU L Perml Inspeption pate: Parameter/Standard — - -- • vv✓ � [ [ /d l Meets SJC Standards? Comments/Measurementsl Recommendations CEMENT PEDESTAL: If `no' is selected, attach an accurate map to permit Yes V Dimensions of surface seal (2'x2'x4" minimum) Yes (�7( Yes l:l ❑ - Casing extends at least 12" above grade Yes EOT Casing extends at least 1" above pedestal Yes ® N❑ Free of cracksicontiguous with -annular seal Yes No ❑ INA ❑ Graded to- allow drainage away from casing JYes Q No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ - Seal between all pipe columns and casing Yes V No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Ghlorination 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 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAIN t LNANL;h: 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 J_f No ❑ NA ❑ Inspected By: Title: � Received By: Date: Yes No ❑ If `no' is selected, attach an accurate map to permit Yes V No ❑ Yes l:l No n Inspected By: Title: � Received By: Date: