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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.slgov.oig/ehd PUMP INSPECTION CHECK LIST A dresso<O +o►o�))h I E' 1 A Z i e L%/" Pe S 4g it � C �J / nsp bon gate: I0 4 ij 2 j2 Parameter/Standard Meets SJC Standards? Comments/M I Recommenndatidati rnen ons CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [2 No ❑ NA ❑ Graded to allow drainage away from casing Yes [il No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing No ❑ NA ❑ —YesQ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 2, Chlorination port available and sealed properly Yes D No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes L� No ❑ NA ❑ Adequately installed check valve or BFP device Yes LZ No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic su ply) 1 Yes ❑ No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA a MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ 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 [2 No ❑ Photograph taken and attached to record Yes [ No ❑ OTHER: Comments: r r Inspected By: Cu, Title: 4SS I,S 6L4 Received By: Date: